New Guidelines for Antibiotic Use Before Dental Procedures

If you have a joint replacement or implant of any kind, you will want to pay attention to these three new Clinical Practice Guidelines. They have been approved by the American Academy of Orthopaedic Surgeons and the American Dental Association Council on Scientific Affairs:

  • Routine use of antibiotics before dental work for people with hip or knee replacements may not be necessary.
  • Use of topical antimicrobial (mouth rinse) is still by patient preference and according to the dentist’s judgment for each individual person.
  • Anyone with a joint implant should be encouraged and educated in proper oral hygiene.

    The evidence for these clinical practice guidelines is limited to inconclusive. This means that the results from currently available research are either unconvincing or show little advantage of one approach over another. So where does that leave us?

    Let’s go back to the beginning and review what has already happened and why these recommendations must be reviewed and updated periodically. In the past, there has been a routine practice of prescribing prophylactic (preventive) antibiotics for patients with joint replacements having dental work done.

    The goal was to avoid infection, which can have serious complications for anyone with a joint replacement. Bacteria in the mouth can travel through the bloodstream and seems to have a preference for the joints. Once a joint with an implant is infected, serious damage and destruction can occur. Another surgery may be needed to clean the joint or even to remove and replace the implant.

    But as you probably already know, the overuse of antibiotics has resulted in stronger, more resistant bacteria called superbugs. Since only two per cent of the people who have hip, knee, or spine implants develop infections, why should everyone be on preventive antibiotics? And since some studies are showing that dental procedures don’t increase the risk of infection, each patient must be considered on a case-by-case basis.

    The trick is to figure out which patients are at increased risk for infection and see if taking prophylactic antibiotics reduces their chances of serious implant complications. It seems that rates of bacterial infection might vary depending on the dental procedure being done. For example, it would seem that pulling a tooth or more invasive procedures might have a higher risk rating. But some people develop infections just from flossing or brushing their teeth.

    Studies looking for individual risk factors (e.g., age, sex, number of dental procedures done) that might explain these differences have yielded contradictory results. Some researchers have looked into various types of antibiotics used to see if that might make a difference. Others have examined the use of different topical antimicrobials (mouth rinses) and how many times it is necessary to use them to prevent infection. As the clinical practice guidelines indicate, there isn’t enough conclusive evidence to recommend for or against the use of oral antimicrobials.

    In summary, with so much left unknown (inconclusive, indirect, or inadequate evidence), dentists must evaluate the risks and benefits of each dental procedure for individual patients who have joint replacements. Right now, there is no known direct link between dental procedures and infection of joints or implants.

    In the end, patient, physician, and dentist must work together to come to an agreement about what is best for each one and plan treatment accordingly. For right now, these three clinical practice guidelines (based on best current evidence) are offered to aid in selecting the plan of care for this group of patients. They are not “stand alone” recommendations but should be considered along with all other factors.