Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental
Executive Summary on the AAOS/ADA Clinical Practice Guideline
Michael P. Rethman, DDS, MS, William Watters, III, MD, Elliot Abt, DDS, Paul A. Anderson, MD, Kevin Boyer, MPH, Karen C. Carroll, MD, FCAP, Richard Parker Evans, MD, Harry C. Futrell, DMD, Kevin Garvin, MD, Stephen O. Glenn, DDS, Michael J. Goldberg, MD, Nicholas B. Hanson, MPH, John Hellstein, DDS, MS, Angela Hewlett, MD, MS, David Kolessar, MD, Calin Moucha, MD, Richard J. O'Donnell, MD, Douglas R. Osmon, MD, John E. O'Toole, MD, Anthony Rinella, MD, Mark J. Steinberg, DDS, MD BACKGROUND
Approximately 200,000 primary total hip arthroplasties and 400,000 primary total knee arthroplasties were performed in the United States in 2003, with a projected increase to 380,000 hip procedures and over 1,500,000 knee procedures in 2020. Orthopaedic implant infection rates range from 0.3% to 8.3% in the published literature included in this guideline.[2-14] These infections can be caused by entry of organisms into the wound during surgery, hematogenous spread, recurrence of sepsis in a previously infected joint, or contiguous spread of infection from a local source.[15] Orthopaedic implant infections can be catastrophic and life threatening. It has long been debated that patients with orthopaedic 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. This potential complex pathway has never been completely elucidated. In order to assess the current state of evidence and provide guidance to clinicians, the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) conducted a systematic review of the literature. The review served as the foundation for new clinical practice guidelines on prevention of orthopaedic implant infection in patients undergoing dental procedures. The following systematic review summarized herein considered literature published through July 2011and demonstrates the best evidence in the relationship of orthopaedic implant infection in patients undergoing dental procedures.(The full review is available at AAOS and ADA staff methodologists and the physician/dentist work group systematically reviewed the available literature and subsequently wrote the following recommendations based on a rigorous, standardized process commensurate with IOM standards.[16, 17] This guideline is an educational tool to guide clinicians through treatment decisions in an effort to improve the quality and effectiveness of care. This guideline should not be construed as including all proper methods of care or excluding methods of care reasonably directed to obtaining the same results. The decision regarding any specific procedure or treatment must be made in light of all circumstances presented by the patient, the needs and resources particular to the locality or institution, and the clinical judgment of the provider. To develop this guideline, the AAOS-ADA work group held an introductory meeting on November 20 and 21, 2010 to establish the scope of the guideline and the systematic review. At the introductory meeting the work group constructed preliminary recommendations which specified [what] should be done in [whom], [when], [where], and [how often or how long]. The preliminary recommendations functioned as research questions for the systematic review, not as final recommendations or conclusions. Upon completing the systematic review, the work group participated in a two-day recommendation meeting on October 15 and 16, 2011 at which time the final recommendations and rationales were edited, written, and voted on. The language and grade of each recommendation was directly influenced by the best available evidence. Economical and adverse outcomes were not formally considered in creating these recommendations per AAOS policy. This guideline was created with the best available evidence as it relates to antibiotic prophylaxis, dental procedures, and orthopaedic implant infections. Detailed information on the literature search, screening, and quality/applicability appraisal can be found in the full guideline ( Forty-seven outside organizations were solicited to provide peer reviewers for this guideline. The draft was sent to seventeen review organizations who responded to the solicitation. The disposition of all non-editorial peer review comments was documented and accompanied this guideline through the public commentary and the AAOS/ADA guideline approval process. The best available evidence published in studies that met the inclusion criteria was considered for this guideline. The following is a summary of this evidence. As illustrated in Figure 1, the quality of evidence that explains the proposed association between dental procedures and orthopaedic implant infection varies. Only one study that provided direct evidence of moderate strength (represented by the arching arrow in Figure 1) was identified by the literature search and considered for this guideline. The results of this study show that dental procedures are not risk factors for subsequent implant infection and furthermore that antibiotic prophylaxis does not reduce the risk of subsequent infection.[18] Implant Infection Moderate Strength Figure 1. Overview of the Evidence
However, a multitude of indirect evidence was included in this guideline that investigates particular components of this complex mechanism. Multiple high strength studies link oral procedures to bacteremia, a surrogate measure of risk for orthopaedic implant infection. Some low strength studies investigate potential risk factors for these bacteremias. In addition, multiple moderate strength studies suggest that prophylaxis decreases the incidence of post dental procedure bacteremia. But no studies explain the microbiological relationship between bacteremia and orthopaedic implant infection. Rates of bacteremia after dental procedures varied significantly by and within dental procedure group. Median incidence rates range from approximately 5% for chewing to upwards of 65% for simple tooth extraction and gingivectomy. (See Figure 2) As expected, the more invasive oral procedures produced the highest median incidence of bacteremia, but common daily habits such as flossing (interdental cleaners), tooth brushing, and even chewing resulted in bacteremia in some cases. Instances of bacteremia following dental procedures may be modified by individual risk factors. While the strength of the evidence is low, several prognostic studies have addressed a multitude of patient characteristics as potential risk factors for developing bacteremia from dental procedures. These low strength studies report on oral health indicators and general patient characteristics such as age, gender, etc. The results, which are often contradictory, vary across and within procedure groups (see full guideline for details).[19-41] No conclusions about risk factors could be drawn from these studies. Bacteremia (Incidence)
Periodontics - Gingivectomy (n=4) Extraction (n=4) Oral Surgery - Extraction (n=4) Prophylaxis (n=5) Periodontics - Probing (n=2) Periodontics - Scaling & Root Planing (n=7) Interdental Cleaners (n=8) Othodontics (n=2) Endodontics (n=5) Intubation (n=6) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Figure 2. Incidence of Bacteremia by Procedure Group (Periodontics-Gingivectom Extractio Oral
Surgery-Extraction, Prophylaxi, Periodontics-Probing Periodontics-Scaling & Root PlaninInterdental Cleaner Orthodontic Endodontics, Brushing, Sialogra, Intubatio,
Sutur Chewin
We recognize the diversity of opinion concerning the clinical importance of bacteremia as a surrogate outcome for orthopaedic implant infection, and understand the clinician's concern and rationale for wanting to prevent bacteremia. Therefore, we conducted two independent network meta-analyses on the efficacy of antibiotic and topical antimicrobial prophylaxis for bacteremia post simple tooth extraction. Other studies exist that investigate different dental procedures, but the most robust data resides in tooth extraction studies. Several studies of moderate strength were included in these analyses. These studies investigated the effect of many different antibiotic drugs and topical antimicrobials. Twenty-one antibiotic studies[32, 37, 45, 49, 67, 81-96], and thirteen topical oral antimicrobial studies[35, 45, 97-107] were included in our network meta-analyses. The majority of the results from the individual studies and the overall effect of these prophylactic agents according to our analyses were favorable and clinically meaningful (Tables 1 and 2). Table 1. Number Needed to Treat (NNT) to Prevent Bacteremia Post Tooth Extraction
Topical Amoxicillin Antiseptic Rinse IM Pen. OR IV Erythro. OR Oral OR IV Amox. Table 2. Number Needed to Treat (NNT) to Prevent Bacteremia Post Tooth Extraction
Chlorhexidine Rinse Povidone-Iodine Rinse Chloramine T Rinse/Brush Lugol's Solution Rinse Hydrogen Peroxide Rinse Sodium Perborate-Ascorbic Acid Rinse Phenolated Rinse Operative Field Isolation Isolation + Iodine Rinse Isolation + Chlorhexidine Rinse While there was no direct evidence to explain the proposed association between bacteremia and orthopaedic implant infection, we summarized the microbiological information pertaining to cases and rates of bacteremia and implant infection when available based on our included literature. According to orthopaedic implant cohort studies[2-14] approximately 53% of organisms responsible for the infections were Staphylococcus species. The overall rate of infection was approximately 1.5%. Of the studies that distinguished early from late infections[2, 5, 6, 9-12, 14] we were able to calculate rates of 0.4% and 0.9% respectively. According to orthopaedic implant infection case series[18, 108-123] approximately 64% of the infections were Staphylococcus species. Of the studies that distinguished early from late infections, 36.7% were early and 63.3% were late[18, 108-112, 114-119, 121]. Dental-related bacteremia varied greatly by procedure and study, as did the organism responsible for the bacteremia.[21, 25, 27, 28, 31, 42, 45-47, 51, 53-57, 59-63, 65, 66, 69, 71, 73-79, 90, 92, 94, 124-140] No clear association between the organisms found in the prosthetic implant infections and bacteremia exists. However, the majority of the organisms found in implant infections are Staphylococcus and the majority of the organisms found as the cause of bacteremias are Streptococcus. (See full guideline for detailed information) Considering all of the above information in accordance with AAOS clinical practice guideline protocol, the workgroup created the following recommendations: Recommendation 1
The practitioner might consider discontinuing the practice of routinely prescribing prophylactic
antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.

Grade of Recommendation: 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
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.

Grade of Recommendation: Inconclusive
An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear
balance between benefits and potential harm.
Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as
and should exercise judgment and be alert to future publications that clarify existing evidence for
determining balance of benefits versus potential harm. Patient preference should have a substantial influencing
Recommendation 3
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.

Grade of Recommendation: 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.
Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus,
although they may set boundaries on alternatives. Patient preference should have a substantial influencing
Direct support for Recommendation 1 comes from a single well-conducted case-control study. Case-control studies are appropriate to answer questions regarding risk factors or etiology. Study enrollment consisted of 339 patients with prosthetic hip or knee infections (cases) and 339 patients with hip or knee arthroplasties without infection (controls) hospitalized on an orthopaedic service during the same time period. The comparison between these groups was for differences in dental visits (exposure) in terms of high and low-risk dental procedures, with and without antibiotic prophylaxis. Results reported as odds ratios with 95% confidence interval, demonstrate no statistically significant differences between groups. Neither dental procedures nor antibiotic prophylaxis prior to dental procedures were associated with risk of prosthetic hip or knee infections. The authors performed a sample size calculation and withdrawals were low, minimizing attrition bias. The prospective nature of this study minimized recall bias. Additionally, blinding of the treatment group to those assessing outcomes limits detection bias. Although this one study of direct evidence was of moderate strength, it did have limitations. The authors conducted covariate analysis on some subgroups of higher risk patients. The number of patients in these subgroups, however, was relatively small, and there is insufficient data to suggest that these patients are at higher risk of experiencing hematogenous infections. Indirect evidence was also considered for Recommendation 1. There is high strength evidence that demonstrates the occurrence of bacteremia with dental procedures. Historically, there has been a suggestion that bacteremias can cause hematogenous seeding of total joint implants, both in the early postoperative period and for many years following implantation. Two years post joint replacement was previously considered the critical period for prophylaxis. In addition, bacteremias may occur during normal daily activities such as chewing and tooth brushing. It is likely that these daily activities induce many more bacteremias than dental-procedure-associated bacteremias. While evidence supports a strong association between certain dental procedures and bacteremia, there is no evidence to demonstrate a direct link between dental-procedure-associated bacteremia and infection of prosthetic joints or other orthopaedic implants. Multiple studies of moderate and high strength evidence suggest that antibiotic prophylaxis decreases the risk of dental-procedure-associated bacteremias. However, dental-procedure-associated bacteremia is a surrogate outcome for prosthetic joint infection. There is no evidence that these bacteremias are related to prosthetic joint infections. Surrogate outcomes may or may not relate to a clinically relevant patient outcome. A positive surrogate outcome (e.g. reduced bacteremias) however, could mask a negative patient-centered outcome (e.g. implant infection). Recommendation 1 is limited to patients with hip and knee prostheses because the single study of direct evidence included only patients with these types of orthopaedic implants. There is no direct evidence that met our inclusion criteria for patients with other types of orthopaedic implants. Evidence for Recommendation 2 is sparse. There was no direct evidence to support or refute the use of prophylaxis (topical antimicrobials) before dental procedures. The same indirect evidence discussed above relating to dental procedures and bacteremia was considered for Recommendation 2. There is conflicting evidence regarding the effect of antimicrobial mouth rinse on the incidence of bacteremia post dental procedures. One high strength study reports no difference in the incidence of bacteremia following antimicrobial mouth rinsing in patients undergoing dental extractions. Conversely, numerous studies suggest that topical antimicrobial prophylaxis decreases the incidence of dental-procedure-associated bacteremia. However, there is no evidence that application of antimicrobial mouth rinses before dental procedures prevents infection of prosthetic joints or other orthopaedic implants. Due to the lack of direct evidence, contradictory nature of the indirect evidence pertaining to topical oral antimicrobials, and continued concern with surrogate outcomes, Recommendation 2 is inconclusive. The work group is unable to recommend for or against the use of topical oral antimicrobials. Recommendation 3 is an opinion statement due to the lack of evidence relating oral hygiene measures to prosthetic joint or other orthopaedic implant infections. 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