Yesterday, the American Dental Association and the American Academy of Orthopedic Surgeons released new, evidence based guidelines regarding antibiotic prophylaxis before dental treatment in patients with joint replacements. The press release states that there is no evidence that dental procedures cause joint infections. Prior to this statement, we were to assume that a dental cleaning or placement of a filling had a special and dangerous power to seed the blood with frightening bacteria that somehow knew to go directly to the joint spaces of innocent artificial knees or hips with the malicious intent to infect.
For years I’ve been complaining to anyone who would listen about the joint replacement conundrum. Even though there was no evidence that premedicating patients was doing anyone any good, we did it. Because giving a patient a giant dose of antibiotics before having dental treatment is a much better option than having to treat or replace an infected joint, right? So just shut up and give them the antibiotics, Doc.
And that’s what we do. Each time I consult with a patient’s surgeon I get similarly frustrated. Some surgeons want premedication for the the rest of the patient’s life. Some surgeons want 6 months. Some want 2 years. Some think Amoxicillin is the way to go. Some say it’s Keflex or nothing. The one thing that all surgeons agree on is that they aren’t going to write the prescription for the antibiotics. That’s the job of the dentist. Which also means it’s the liability of the dentist. Let’s face it. Some patients can develop hypersensitivity to antibiotics and a huge dose of antibiotics could cause a reaction. Even a potentially severe reaction. And no one wants to be the one who wrote that script, right?
Let’s just get this out of the way. Most dentists don’t believe we’re doing a valuable service by premedicating our patients. Most of us know that eating a Dorito is at least as great of a risk as a dental cleaning for seeding the blood with oral bacteria. But we’re not rushing to premedicate patients prior to Dorito consumption. We’re doing it to cover our asses! We’ve been trained to cover our asses about this stuff since dental school. It has nothing to do with excellent patient care and everything to do with making sure we did everything right so that if some future joint infection or infective endocarditis event comes along we can prove that “it wasn’t us.” If it was really about excellent patient care, we’d have the ADA lobbying Frito Lay to bring out “Blazin’ Amoxicillin” Doritos.
I’m a dentist. My strength is treating dental disease. I’m a pretty smart guy, but frankly I’m not really up on the real risks of artificial joint infection or antibiotic allergies. How can I be expected to weigh the likelihood of two incredibly rare but very serious outcomes (joint infection vs. antibiotic reaction)? I don’t think it’s legitimate for the dentist to have their own policy. How about if the professional group that represents me, the American Dental Association, gives me some solid guidance so I don’t have to worry that I’ll be 1) harming my patients by not correctly weighing the risk factors and 2) you know…the lawyers.
But now, the evidence (or lack thereof) is in! We can stop worrying about the premedication for people with joint replacements because there’s no evidence of harm, right?
What the joint ADA-AAOS actually gives us are 3 “guideline recommendations.”
But recommendations are good, right? After all, the American Heart Association passed down (many times!) their recommendations on stone tablets for all dentists to know and heed! And by following recommendations it means that the lawyers can’t get us! I mean, as long as we follow the recommendations!
You’d think so. I mean, you’d think that having recommendations from the two big professional groups representing dentists and orthopedic surgeons would give us actual guidance on this issue. But it’s just not true.
The ADA-AAOS statement made me skeptical almost as soon as I started reading.
This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, dentist and other healthcare practitioners.
I read that and think, “these guidelines are perfectly fine, except you still have to evaluate patients on a case by case basis and if you get sued, we don’t have your back.”
I have to admit that I haven’t taken the time to read the full guideline, so my comments are based on the summary. The full guideline is somewhere around 100 pages and my own inability to concentrate for that length of time (thanks, internet!) has kept me from reading it. If someone does read it and find that I’m completely wrong, please let me know. I’d love to be wrong about this.
The recommendations strike me as incredibly watered down. They seem to be written as obliquely and indirectly as possible. Then each of them is given a “strength of recommendation” rating which means nothing to me. And they know this. So they give a definition about the strength of rating. Right after they give the strength of the rating. Honestly, it’s kind of bizarre.
The first recommendation addresses the use of prophylactic antibiotics:
The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.
I might consider discontinuing antibiotics. Sure. I might. I might consider explaining my position to the patient, too. I mean they are the ones that are taking the very slight (but real!) risk here. But did I really need a recommendation from the ADA and the AAOS to tell me that I might think about it?
Further bolstering my opinion of this recommendation is the “strength of recommendation” score it’s given: “limited.”
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.
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.
Recommendation 2 speaks to the use of preoperative topical oral antimicrobials:
We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures.
So, they won’t say whether use of chlorhexidine prior to your filling is worth it or not. Great. Thanks for that. This strikes me as unnecessary because the risk profile of a swish of Peridex is a lot less than a megadose of Amoxicillin. In any case, they want us to know that we should feel “little contraint” in deciding whether to follow this recommendation. Gee, thanks.
Finally, the most bizarre recommendation.
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 orthopaedic implants maintain appropriate oral hygiene.
Really? Was there a time when I was supposed to be telling joint replacement patients that the risk of joint infection was so great that the shouldn’t floss? Or am I to assume that the ADA and AAOS feel that maintaining oral hygiene is vital to the health of an artificial joint? Honestly, I don’t even know what they’re trying to say. But at least they all agree on it. They give this recommendation a strength of: “consensus.”
A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria.
I had high hopes that the ADA would come through for us on this issue. I was hoping for an “AHA-like” guideline that would take the guessing out of this very common event for dental patients and dentists alike. It didn’t happen.
The most hopeful statement I got from the new guidelines is this:
Patient preference should have a substantial influencing role.
Although this statement was made specifically in reference to recommendation 2, I think it’s worth contemplating for the whole thing. Taking a large dose of antibiotics prior to dental appointments is not a risk-free event. I honestly don’t know if the data exists to weight the risk of taking antibiotics against the risk of joint infection at the dental office. I think patients can and should be part of the decision here.
The whole inconclusive data issue cuts both ways. Sure, there is no data to conclude that dental treatment causes joint infections. However, outside interests can just as easily claim that there isn’t data that dental treatment doesn’t cause infection in artificial joints. As a profession, we’re in the exact same spot that we were before these so called recommendations came out. We’re still going to cover our asses for the wrong reasons. It wasn’t good medicine before and it still isn’t.
What do I think should happen? I think the ADA and AAOS should sound off like they’ve got a pair. I think they should put a statement out that they’re going to help fund research on this topic to really answer the question and in the mean time they need to make a statement to dentists that “this is the recommendation and we’ve got your back if there’s a problem.” I think that the ADA should set aside a fund for the inevitable legal challenges that will come along to such a definitive statement and let member dentist’s know that they will be represented. It’s time to do the right thing for the right reason.
Am I right on the money? Am I completely dead wrong? I’d like to hear what you think. Feel free to leave a comment here or email me at firstname.lastname@example.org.
Another amazing article Alan! You are truly one of dentistry’s thousand points of light! Your biggest fan and admirer, Howard Farran
I am always proud to say I am a Dentist….after reading such an inteligent piece like this…thanks !!
Not a member of the ADA since 1985. Howard once said..”would’nt be better to buy a nice couch for you living room”
The ADA simply sucks. It’s a spineless organization. And, this is just another example of why.
I dropped out of the ADA many years ago, and gosh-darn-it… they keep confirming my decision!
Mike, how often do you run into the joint replacement conundrum and what do you normally do?
Research to date shows there is no correct answer to that question. ADA and AAOS pretty well states that. They have basically covered all of our asses with this in that you can make an argument to do anything and not be wrong. Of course if something happened and you got sued, well there is no science to predict outcome of lawsuits so just be nice to your patients.
I disagree that the ADA/AAOS statement “covers” us at all. Basically, we’re waiting for a test case to offer a legal precedent. Instead of offering evidence and guidance, it offers a lukewarm rehash of what we were doing before. This is ALL about getting sued now. It’s tragic that any helpful “guidelines” will be coming from whatever legal precedent is set.
C’mon ADA, help us out a bit. Why can’t guidelines be created to standardize this for dentists? Bad representation by the ADA.
Check out this article in the local rag. Not really covering antibiotic prophylaxis but it may imply a direct link from tooth to artificial knee
Spot on Doc!
I recently attended a Grand Rounds session at the big ortho hospital here, and they were all about prophylaxis in all JR patients, for life! And they’re what I would consider a fairly big ortho group here. Interesting contradiction.
Most of my patients are migrants Hispanics, and rarely show up for elective dental work. Thus, I end up giving them antibiotics immediately following their OS anyway. The ones that do have JR are sickly looking anyway, and meet, “my,” inclusion criteria for prophylaxis.
I’m going to share this on my page, Alan!
Great article and as always, Alan, you have an extremely credible perspective…
I am always proud to say I am a Dentist…. After reading such an intelligent piece like this. Well done!
I’m with sherm on this one, and i feel the same way about heart murmurs as i do joint replacements; if i’m doing full mouth srp’s or an extraction in a very dirty mouth, the pt def gets antibiotics. i’ve seen bacterial endocarditis after ext’s in a patient with a filthy mouth and an undiagnosed heart murmur. the aha and ada can change guidelines all they want, but i’m still going to go with my gut.
Is a patient allowed to chip in on this one? I’ve been doing my own research on antibiotic prophylaxis because of conflicting and confusing advice I am receiving. I had a hip replacement 6 years ago and was advised that I would need to premedicate for the rest of my life prior to a dental procedure.
I am 66 years old, female, in good health, and take no other medications. However, I do have periodontal issues that are being mostly stabilized by regular dental cleanings that have increased from every 3 months to every 8 weeks. Each time, I premedicate — 2 grams Amoxicillin one hour before. I am what I think dentists call a “compliant” patient. Very compliant.
I trust and respect my dental hygienist and my dentist who have worked together with me over 20 years. My personal dental hygiene practices verge on the obsessive, but in the end, despite all our best efforts, it looks like bad genes might well win out. They usually do — which brings me back to antibiotic prophylaxis.
After reading ADA recommendations, revised recommendations, other dental and medical recommendations, not to mention various “hedging my bets” and “covering my ass” recommendations, I have decided to no longer premedicate — starting with my root canal tomorrow. I think my regular dentist (who won’t be doing the root canal) will be just fine with my decision. The problem will be to convince my conscientious, meticulous hygienist.
Great blog. Thanks.
I have been a patient of your dad’s practice for many years. I have one full and one partial knee replacement. I have taken the pre-dental meds for 8 years and will continue to do so – at least for mow. Thanks for the article.
Alan, I realize your piece, which I just came across, is several years old, but it is just as relevant, unfortunately, as if it were written yesterday. This is from a patient’s viewpoint: I’ve been caught up in the stressful controversy about whether antibiotics are necessary prior to virtually all dental procedures, including cleanings, for the last several years, as I have severe hip arthritis that I’m told would benefit from replacement surgery. (I actually cancelled my first scheduled hip op, two years ago, due to this controversy.) I need three dental cleanings per year due to frequent plaque buildup. In a “bad year,” I might also need a root canal and/or crown replacement. I also have a medical condition that has required a wide-spectrum antibiotic every few years. Added to the requisite dental cleanings, a “bad year” could see me taking wide-spectrum antibiotics up to six times! This is risky in the extreme, especially relative to the risk it poses for C. difficile colitis (which I had after a course of clindamycin for tear-duct surgery). I think your points are excellent; it’s hard to imagine who wouldn’t be massively confused by the “recommendations” and all of the tiers of “evidence.” I do disagree, though, with your statement that the risk of harm after premedicating with amoxicillin is slight, as MANY patients report having contracted C. difficile even from low doses of dental antibiotics. (I know this from my participation on an online patient forum.)
Would you be willing to update your piece with a few comments on how you currently view this confusing situation? Hopefully, that would invite further comments from patients and practitioners. With this week’s headline news about a new E. coli superbug that is resistant to all antibiotics, this topic couldn’t be more important or timely.
Thanks for an excellent post. Same thoughts and problems in Finland.
I’m interested in the legal aspect – how stressful is it to think of it? In the US, it seems to be much more disturbing than in Europe. I mean, there are moments when I’m not sure what to do and I end up thinking “hmmm, if I end up in jail, I guess that must be a cosy place”. Not very afraid of it!
We had a bad incident in HUSLAB (main blood sampling laboratory in Helsinki) in March this year. A lab assistant normally working somewhere else had come in for a day and was meant to take blood samples in one of the lab rooms. She knew how to do it and worked all morning without problems. She ran out of needles by midday and after searching for new ones, found a box where the previous worker had put used “safety” needles the previous day. She thought they were new and unused, and she had never seen a safety needle before. Only a few hours later she found another box where there were actual unused safety needles. At that moment she realized what the unused ones really look like. She panicked. She got home and called the boss, telling what had happened. She had taken about 20 blood samples using the contaminated needles.
What would’ve happened in the US after this?
In Helsinki, they instantly reacted on the phone call of the worker, investigated the whole case thoroughly, made the report public yesterday and by new safety standards, prevented the same thing from happening again. But no-one ended up in jail. No worker had to pay for anyone. It was _just_ a bad mistake, and many separate factors led to the outcome.
Somehow I really like that – it’s not always someones fault only. Things just happen and we STILL can learn from them.