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Dental Care and The Prosthetic Joint Patient: A Survey of Orthopedic Surgeons and General Dentists
C L IN IC A L
—
DENTAL CARE AND THE PROSTHETIC JOINT PATIENT:
A SURVEY OF ORTHOPEDIC SURGEONS AND GENERAL DENTISTS MICHAEL K. SHROUT,
FRANK SCARBROUGH; BILLY J. POWELL , D.M.D.
Q he need for antibiotic prophylaxis in dental patients with prosthetic joints has been debated for a t least 13 years.1 On one side are those who associate late prosthetic joint infections (LPJI) with distant foci of infections, including dental infections or treatm ent.25 Proponents also cite the catastrophic morbidity of joint failures, the 18 percent mortality rate of LPJI and strong support for chemo prophylaxis from orthopedic surgeons.610 On the other side are those who say there’s a lack of scientific evidence to link transient bacteremia caused by dental procedures with pros thetic joint infections.41014 Some experts also report a low incidence of hematogenous spread of bacteria from even chronic dental infection and note th a t the bacteria causing most LPJI have small popula tions in the mouth.4'5101216 Both sides lack a consensus on the best antibiotic to prevent LPJI.8'10111317 In the years of discussion, the closest the two have come to agreement concerns the need to consult the p atient’s orthopedic surgeon before dental treatm ent.1’4'81018 We conducted this study to
A
B
S
T
R
A
C
T
Orthopedic surgery and general dentistry residency program directors were surveyed about treatment considerations for dental patients with prosthetic joints. The majority believed dental diseases can affect joint prostheses and thought orthopedic surgeons should be consulted before dental treatment. Both groups recommended antibiotic prophylaxis for these patients.
collect opinions of orthopedic surgeons and general dentists on prophylaxis for dental patients with artificial joints, and compare the two in light of the diverse opinions expressed in the literature. METHODS
We designed a mail survey to collect opinions on: * the potential of dental infections to contribute to LPJI; ■» the need for consultation with the patient’s orthopedic surgeon; ■» the need for chemopro
phylaxis during dental care; ■» which prostheses are at highest risk after dental treatm ent for LPJI; •*» how long after prosthetic surgery the patient will require chemoprophylaxis ; ■* the preferred drug for prophylaxis. Respondents also were asked to contribute any other pertinent information. To revalidate information collected in studies 8 years ago,910 we sent questionnaires to the directors of 110 accredited, orthopedic surgery residency programs. We also surveyed directors of 63 general dentistry residency programs. (We thought residency program directors represented general dentists who were wellinformed on the overall needs of medically compromised patients). Surveys were sent to a t least one, randomly selected, pro gram in every state. To account for population distribution, we sent surveys to two programs in the most populous cities and states. The survey sent to the dentists paraphrased the same questions sent to the surgeons, except it did not ask the dentists to estimate the number JADA, Vol. 125, April 1994
429
CLINICAL PRACTICE
of prosthetic infections th at resulted from dental sources. RESULTS
Two of the 173 surveys were returned as unmailable. Responses were received for 80 of the remaining 171 surveys, or 46 percent. The orthopedic surgeons returned 44 of 108 surveys, or 41 percent (both unmailable surveys had been sent to surgeons). Thirty-six out of 63 (57 percent) of the dentists responded. The response rates for the dentists and the study overall
met the 43 percent standard suggested to minimize non response bias in mailed surveys.19The 41 percent physician response, while minimal, was acceptable considering they were surveyed to validate previous study results. Both groups believed dental diseases or infections are or can be a source of bacteremias th a t may affect joint prostheses (93 percent of the orthopedists and 75 percent of the dentists). The physicians’ mean estimate was th a t 9 percent of prostheses
infections resulted from dental sources (the mode response was 5 percent). Both groups also thought the dentist should consult the orthopedic surgeon before any treatm ent th at might induce a bacteremia in patients with a prosthetic orthopedic appliance (72 percent of the orthopedists and 78 percent of the dentists). Ninety-eight percent of the surgeons believed patients who have had joint surgery should take prophylactic antibiotics before dental treatm ent. Of this group, 17 percent believed
TA BLE
TREATMENT CONSIDERATIONS FOR DENTAL PATIENTS WITH ARTIFICIAL JOINTS ACCORDING TO SURVEYED ORTHOPEDIC SURGEONS AND DENTISTS. ORTHOPEDIC SURGEONS (%)
DENTISTS (%)
D e n ta l d is e a s e s or in fectio n s can affect jo in t p r o sth e se s
93
75
O rthopedic su rg eo n sh ou ld be co n su lted before d e n ta l tr e a tm e n t
72
78
P a tie n ts sh ou ld ta k e a n tib io tic s before d en ta l tr e a tm e n t after: a n y jo in t su rgery
17
19
p ro sth e tic jo in t rep la cem en t
81
66
m ajor jo in t rep la cem en t
54
24
a n y jo in t rep la cem en t
46
81
A n tib io tics sb o u ld be prescribed before d e n ta l trea tm en t: 6 m o n th s after su rg ery
O
X y ea r a fter su rg ery
8
7
92
63
p e n ic illin s (in clu d in g a m oxicillin )
29
61
cephal osporins
71
38
for life
30
D ru g o f choice
A lte r n a te drug o f choice ery th ro m y cin
45
57
v an com ycin
14
4
ciprofloxacin
IO
O
cep h a lo sp o rin s
IO
8
7
23
clin d a m y cin
430
JADA, Vol. 125, April 1994
patients who have had any joint surgery should be included, while 81 percent would premedicate only patients who have had prosthetic replace m ent surgery. They did not clearly m andate which prostheses should be covered; 54 percent said only major joints (knees and hips, for example), while 46 percent thought th a t all joints should be included. This is compared with 81 percent of the dentists who thought any patient with an artificial joint should be premedicated. Ninety-two percent of the physicians and 63 percent of the dentists agreed th a t patients who have had joint surgery should receive prophylactic antibiotics before dental treatm ent for the rem ainder of their lives. Surgeons and dentists disagreed on the drug of choice for prophylaxis. Seventy-one percent of the surgeons chose cephalosporins and 29 percent opted for penicillins. Sixty-one percent of the dentists chose penicillins (including 24 percent who selected amoxicillin specifically) and 38 percent preferred cephalosporins. Erythromycin was the most accepted alternate medication (dentists, 57 percent; physi cians, 45 percent). Twenty-three percent of the dentists also recommended clindamycin. Vancomycin, clindamycin, ciprofloxacin and cephalosporin were each recommended by about 10 percent of the physi cians as the alternate drug of choice.
ongoing. Generally, the two sides align according to aca demic and practitioner view points. One camp includes groups like the American Academy of Oral Medicine and the British Society for Anti microbial Chemotherapy; the other is made up of individual orthopedic surgeons, who have the ultim ate responsibility for the patient and joint.1618 Our findings were consistent
Both groups believed den tal diseases or infections are or can be a source of bacteremias that m ay affect joint prostheses. with other studies of orthopedic surgeons.910 Although only 41 percent of the respondents in the Jaspers and Little study considered the relationship between dentally induced bacteremias and secondary prosthetic joint infections wellestablished or at least impor tant, 93 percent considered antibiotic prophylaxis neces sary.10In the Howell and Green study, 94 percent of the respondents thought dental infections affect joint prostheses, with the same Dr. Shrout is an associate professor, Oral Diagnosis and Patient Services, School of Dentistry; and an associate professor, Oral Biology, School of Graduate Studies,
DISCUSSION
Medical College of Georgia, Augusta
The debate about chemopro phylaxis for dental patients who have prosthetic joints has been 432
JADA, Vol. 125, April 1994
30912-1241. Address reprint requests to Dr. Shrout.
percentage suggesting prophylaxis before dental treatm ent.9 Our results were similar, with 93 percent believing there was a relationship and 98 percent recommending prophylaxis. Significantly, advocates of both sides of the argument say the orthopedic surgeon should be consulted concerning cov erage.1'4'810’18Also, the majority of surgeons consistently have favored antibiotic prophyl axis.910 Our decisions as practitioners should be influ enced by the knowledge th a t 93 to 98 percent of our consultants have one opinion, particularly if the patient’s orthopedic surgeon is not available. Dentists and orthopedic surgeons had nearly inverse opinions on which antibiotic should be used. In our survey, orthopedic surgeons recom mended cephalosporins over penicillins (71 vs. 29 percent). This was consistent with the Howell and Green, and Jaspers and Little surveys in which 62 and 70 percent of orthopedic surgeons, respectively, prefer red cephalosporins compared to 19 and 13 percent of those who chose penicillins.910 The dentists in our survey, however, were 61 vs. 38 percent in favor of penicillins over cephalosporins, including 24 percent th a t selected amoxi cillin specifically. Possibly, the dentists were combining the prophylactic regimens for prosthetic joint infections and bacterial endocarditis into one category. More likely, the debate in the dental literature has divided and confused the profession. Based on our results, argu ments about which antibiotic is most effective against oral
CLINICAL PRACTICE
bacteria vs. which is most effective against LPJI-causing bacteria are less im portant than the calibration of dental practitioners’ opinions against those of prim ary care providers, in this case orthopedic surgeons. In lieu of a comprehensive controlled study or an interdis ciplinary joint committee recom mendation, dentists must rely on other data to determine the need for chemoprophylaxis for these patients. In one study, researchers reviewed almost 2,700 hospital and dental records to investigate microorganisms associated w ith LPJI.20They concurred with the orthopedic surgeons th a t cephalosporins are indicated for dental patients with prosthetic joints. A cost-effectiveness analysis of 1 million hypothetical dental patients who had prosthetic joints suggested th a t no prophylaxis is a reasonable general policy.21 However, the authors recommended a one day oral cephalexin regimen for “high-risk” prosthetic patients. High-risk patients were defined in the article as individuals with previous complications of the prosthetic joint, including a history of infections, surgery and joint loosening; or, predis posing systemic illness including rheumatoid arthritis, diabetes mellitus or immunosupression while undergoing a dentally induced bacteremia for longer than 3 minutes. The authors suggested th a t an oral cephalexin strategy would decrease the risk of outcomes including death and am puta tions, compared to no prophylaxis. The use of penicillin was never determined as cost effective in this study. In the Howell and Green 434
JADA, Vol. 125, April 1994
survey, 32 percent of the surgeons recommended erythromycin as the alternative preferred drug, and 45 percent of the surgeons in our study concurred.9Fifty-seven percent of the dentists were also of th at opinion. Two other studies support the use of erythromycin to pre vent LPJI after dental treat-
Physicians and dentists agreed that patients who have had joint surgery should receive prophylactic antibiotics before dental treatment fo r the rem ainder of their lives. ment, although not necessarily as an alternate. The first was a cost-effectiveness analysis evaluating whether patients with artificial joints should take penicillin, erythromycin or no antibiotics before dental proce dures.13Although erythromycin is slightly more expensive, it was deemed the most costeffective prophylactic because it carries no risk of anaphylaxis. The second study reviewed almost 2,000 prosthetic hip replacement cases. The authors evaluated patients’ charts; microbiology laboratory reports on the 33 cases th a t became infected, of which only one could be associated with dental trea t ment; and the identity and drug sen Mr. Scarbrough is a research assistant, sitivities of the School of Dentistry, infecting Medical College of Georgia. organisms.11
Based on the drug sensitivities of the most common infecting organisms, the authors recommended erythromycin, clindamycin or a penas eresistant penicillin. CONCLUSION
Dentists and orthopedic surgeons in our survey agreed th a t dentists should consult with orthopedic surgeons before treating patients with major joint prostheses. They did not concur on a preferred drug for prophylaxis. However, considering the available data, opinions of the orthopedic surgery community and a lack of any study to the contrary, cephalosporins or erythromycin should be the primary prophylactic agent for dental patients who have prosthetic joints. Based on our survey results and review of the literature, we also recommend: ■** consultation with the patient’s orthopedic surgeon before any invasive dental treatm ent; ■ aggressive treatm ent of any dental infection in patients with prosthetic joints; *■ additional research to determine the relationship between dental treatm ent and LPJI; ■* development of guidelines by orthopedic surgeons and den tists for the dental management of patients with prosthetic joints. ■ The opinions expressedorimpliedare strictly those of the authors anddonot necessarilyreflect the opinionorofficial policies oftheAmericanDental Association. 1. PetersonLJ. Prostheticjoint infection anddental procedures. JADA1980;101:598600. 2. Downes EM . Late infectionaftertotal hip replacement. JBone Joint Surg 1977;59:42-4. 3. StinchfieldFE, Bigliani LU, Neu HC, Goss TP, Foster CG. Late hematogenous
CLINICAL PRACTICE
"YOUR FREE CATALOG KNOCKED MY SOCKS OFF" We get that sort of comment all the time. People are impressed that our free Consumer Information Catalog lists so many free and low-cost government booklets. There are more than 200 in all, containing a wealth of valuable information. They tell you how to make money, how to save money and how to invest it wisely. They tell you about federal benefits, housing, jobs, and learning activities for children. They fill you in on nutrition, health and much, much more. Our free Catalog will very likely impress you, too. But first you have to get it. Just send your name and address to:
Consumer Information Center Department KO Pueblo, Colorado 81009
infectionoftotal joint replacement. J Bone Joint Surg 1980;62:1345-50. 4. LittleJW . The needforantibiotic coverage for dental treatment ofpatients with joint replacements. Oral SurgOral M edOral Pathol 1983;55:20-3. 5. SullivanPM , JohnstonRC, Kelly SC. Late infectionaftertotal hipreplacement causedby anoral organismafterdental manipulation. J Bone Joint Surg 1990;72:121-3. 6. RubinR, Salvati EA, Lewis R. Infected total hipreplacement after dental procedures. Oral SurgOral M edOral Pathol 1976;41:1823. 7. AhlbergA, CarlssonAS, LindbergL. Hematogenous infectionintotaljoint replacement. ClinOrthop 1978;137:69-75. 8. MulliganR. Late infections inpatients withprostheses fortotal replacement of joints: Implications forthe dental practitioner. JADA1980;101:44-6. 9. Howell RM , GreenJG. Prophylactic antibiotic coveragein dentistry: Asurvey of needforprostheticjoints. GenDent 1985;33:320-3. 10. Jaspers M T, Little JW . Prophylactic antibiotic coverageinpatients withtotal arthroplasty: current practice. JADA 1985;111:943-4. 11. JacobsenPL, M urryW . Prophylactic coverage ofdental patients with artificial joints: Aretrospective analysis ofthirty-three infections inhipprostheses. Oral SurgOral M edOral Pathol 1980;50:130-3. 12. JacobsonJJ, M illardHD, Plezia R, BlankenshipJR. Dental treatment andlate prostheticjoint infections. Oral SurgOral M edOral Pathol 1986;61:413-7. 13. Tsevat J, Durand-Zaleski I, Pauker SG. Cost-effectiveness ofantibiotic prophylaxis for dental procedures inpatients withartificial joints. AmJ Public Health 1989;79:739-43. 14. Council onDental Theraputics. Management ofdental patients with prostheticjoints. JADA1990;121:537-8. 15. McGowanDA, Hendrey M L. Is antibiotic prophylaxis requiredfordental patients withjoint replacements?Brit Dent J 1985;158:336. 16. Simmons NA, Ball AP, CawsonRA, et al. Case against antibiotic prophylaxis for dental treatment ofpatients withjoint prostheses. (letter) Lancet 1992;339:301. 17. Cioffi GA, TerezhalmyGT, Taybos GM . Totaljoint replacement: Aconsiderationfor antimicrobial prophylaxis. Oral SurgOral M edOral Pathol 1988;66:124-9. 18. Eskinazi D, RathbunW . Is systematic antimicrobial prophylaxisjustifiedindental patients withprostheticjoints? (editorial) Oral Surg Oral M edOral Pathol 1988;66:4301. 19. HoulandES, RombergE, MorelandEF. Nonresponse bias tomail surveyquestion naires within aprofessional population. J Dent Educ 1980;44:270-4. 20. JacobsonJJ, Matthews LS. Bacteria isolatedfromlate prostheticjoint infections: Dental treatment andchemoprophylaxis. Oral Surg Oral M edOral Pathol 1987;63:1226.
21. JacobsonJJ, Schweitzer SO, Kowalski CJ. Chemoprophylaxis ofprostheticjoint patients duringdental treatment: Adecisionutility analysis. Oral SurgOral M edOral Pathol 1991;72:167-76. 22. NelsonJP, FitzgeraldRH, Jaspers M T, LittleJW . Prophylacticantimicrobial coverage inarthroplasty patients (editorial). J BoneJoint Surg1990;72(1):1. A public service of this publication and the Consumer Information Center of the U. S. General Services Administration
—
DENTAL CARE AND THE PROSTHETIC JOINT PATIENT:
A SURVEY OF ORTHOPEDIC SURGEONS AND GENERAL DENTISTS MICHAEL K. SHROUT,
FRANK SCARBROUGH; BILLY J. POWELL , D.M.D.
Q he need for antibiotic prophylaxis in dental patients with prosthetic joints has been debated for a t least 13 years.1 On one side are those who associate late prosthetic joint infections (LPJI) with distant foci of infections, including dental infections or treatm ent.25 Proponents also cite the catastrophic morbidity of joint failures, the 18 percent mortality rate of LPJI and strong support for chemo prophylaxis from orthopedic surgeons.610 On the other side are those who say there’s a lack of scientific evidence to link transient bacteremia caused by dental procedures with pros thetic joint infections.41014 Some experts also report a low incidence of hematogenous spread of bacteria from even chronic dental infection and note th a t the bacteria causing most LPJI have small popula tions in the mouth.4'5101216 Both sides lack a consensus on the best antibiotic to prevent LPJI.8'10111317 In the years of discussion, the closest the two have come to agreement concerns the need to consult the p atient’s orthopedic surgeon before dental treatm ent.1’4'81018 We conducted this study to
A
B
S
T
R
A
C
T
Orthopedic surgery and general dentistry residency program directors were surveyed about treatment considerations for dental patients with prosthetic joints. The majority believed dental diseases can affect joint prostheses and thought orthopedic surgeons should be consulted before dental treatment. Both groups recommended antibiotic prophylaxis for these patients.
collect opinions of orthopedic surgeons and general dentists on prophylaxis for dental patients with artificial joints, and compare the two in light of the diverse opinions expressed in the literature. METHODS
We designed a mail survey to collect opinions on: * the potential of dental infections to contribute to LPJI; ■» the need for consultation with the patient’s orthopedic surgeon; ■» the need for chemopro
phylaxis during dental care; ■» which prostheses are at highest risk after dental treatm ent for LPJI; •*» how long after prosthetic surgery the patient will require chemoprophylaxis ; ■* the preferred drug for prophylaxis. Respondents also were asked to contribute any other pertinent information. To revalidate information collected in studies 8 years ago,910 we sent questionnaires to the directors of 110 accredited, orthopedic surgery residency programs. We also surveyed directors of 63 general dentistry residency programs. (We thought residency program directors represented general dentists who were wellinformed on the overall needs of medically compromised patients). Surveys were sent to a t least one, randomly selected, pro gram in every state. To account for population distribution, we sent surveys to two programs in the most populous cities and states. The survey sent to the dentists paraphrased the same questions sent to the surgeons, except it did not ask the dentists to estimate the number JADA, Vol. 125, April 1994
429
CLINICAL PRACTICE
of prosthetic infections th at resulted from dental sources. RESULTS
Two of the 173 surveys were returned as unmailable. Responses were received for 80 of the remaining 171 surveys, or 46 percent. The orthopedic surgeons returned 44 of 108 surveys, or 41 percent (both unmailable surveys had been sent to surgeons). Thirty-six out of 63 (57 percent) of the dentists responded. The response rates for the dentists and the study overall
met the 43 percent standard suggested to minimize non response bias in mailed surveys.19The 41 percent physician response, while minimal, was acceptable considering they were surveyed to validate previous study results. Both groups believed dental diseases or infections are or can be a source of bacteremias th a t may affect joint prostheses (93 percent of the orthopedists and 75 percent of the dentists). The physicians’ mean estimate was th a t 9 percent of prostheses
infections resulted from dental sources (the mode response was 5 percent). Both groups also thought the dentist should consult the orthopedic surgeon before any treatm ent th at might induce a bacteremia in patients with a prosthetic orthopedic appliance (72 percent of the orthopedists and 78 percent of the dentists). Ninety-eight percent of the surgeons believed patients who have had joint surgery should take prophylactic antibiotics before dental treatm ent. Of this group, 17 percent believed
TA BLE
TREATMENT CONSIDERATIONS FOR DENTAL PATIENTS WITH ARTIFICIAL JOINTS ACCORDING TO SURVEYED ORTHOPEDIC SURGEONS AND DENTISTS. ORTHOPEDIC SURGEONS (%)
DENTISTS (%)
D e n ta l d is e a s e s or in fectio n s can affect jo in t p r o sth e se s
93
75
O rthopedic su rg eo n sh ou ld be co n su lted before d e n ta l tr e a tm e n t
72
78
P a tie n ts sh ou ld ta k e a n tib io tic s before d en ta l tr e a tm e n t after: a n y jo in t su rgery
17
19
p ro sth e tic jo in t rep la cem en t
81
66
m ajor jo in t rep la cem en t
54
24
a n y jo in t rep la cem en t
46
81
A n tib io tics sb o u ld be prescribed before d e n ta l trea tm en t: 6 m o n th s after su rg ery
O
X y ea r a fter su rg ery
8
7
92
63
p e n ic illin s (in clu d in g a m oxicillin )
29
61
cephal osporins
71
38
for life
30
D ru g o f choice
A lte r n a te drug o f choice ery th ro m y cin
45
57
v an com ycin
14
4
ciprofloxacin
IO
O
cep h a lo sp o rin s
IO
8
7
23
clin d a m y cin
430
JADA, Vol. 125, April 1994
patients who have had any joint surgery should be included, while 81 percent would premedicate only patients who have had prosthetic replace m ent surgery. They did not clearly m andate which prostheses should be covered; 54 percent said only major joints (knees and hips, for example), while 46 percent thought th a t all joints should be included. This is compared with 81 percent of the dentists who thought any patient with an artificial joint should be premedicated. Ninety-two percent of the physicians and 63 percent of the dentists agreed th a t patients who have had joint surgery should receive prophylactic antibiotics before dental treatm ent for the rem ainder of their lives. Surgeons and dentists disagreed on the drug of choice for prophylaxis. Seventy-one percent of the surgeons chose cephalosporins and 29 percent opted for penicillins. Sixty-one percent of the dentists chose penicillins (including 24 percent who selected amoxicillin specifically) and 38 percent preferred cephalosporins. Erythromycin was the most accepted alternate medication (dentists, 57 percent; physi cians, 45 percent). Twenty-three percent of the dentists also recommended clindamycin. Vancomycin, clindamycin, ciprofloxacin and cephalosporin were each recommended by about 10 percent of the physi cians as the alternate drug of choice.
ongoing. Generally, the two sides align according to aca demic and practitioner view points. One camp includes groups like the American Academy of Oral Medicine and the British Society for Anti microbial Chemotherapy; the other is made up of individual orthopedic surgeons, who have the ultim ate responsibility for the patient and joint.1618 Our findings were consistent
Both groups believed den tal diseases or infections are or can be a source of bacteremias that m ay affect joint prostheses. with other studies of orthopedic surgeons.910 Although only 41 percent of the respondents in the Jaspers and Little study considered the relationship between dentally induced bacteremias and secondary prosthetic joint infections wellestablished or at least impor tant, 93 percent considered antibiotic prophylaxis neces sary.10In the Howell and Green study, 94 percent of the respondents thought dental infections affect joint prostheses, with the same Dr. Shrout is an associate professor, Oral Diagnosis and Patient Services, School of Dentistry; and an associate professor, Oral Biology, School of Graduate Studies,
DISCUSSION
Medical College of Georgia, Augusta
The debate about chemopro phylaxis for dental patients who have prosthetic joints has been 432
JADA, Vol. 125, April 1994
30912-1241. Address reprint requests to Dr. Shrout.
percentage suggesting prophylaxis before dental treatm ent.9 Our results were similar, with 93 percent believing there was a relationship and 98 percent recommending prophylaxis. Significantly, advocates of both sides of the argument say the orthopedic surgeon should be consulted concerning cov erage.1'4'810’18Also, the majority of surgeons consistently have favored antibiotic prophyl axis.910 Our decisions as practitioners should be influ enced by the knowledge th a t 93 to 98 percent of our consultants have one opinion, particularly if the patient’s orthopedic surgeon is not available. Dentists and orthopedic surgeons had nearly inverse opinions on which antibiotic should be used. In our survey, orthopedic surgeons recom mended cephalosporins over penicillins (71 vs. 29 percent). This was consistent with the Howell and Green, and Jaspers and Little surveys in which 62 and 70 percent of orthopedic surgeons, respectively, prefer red cephalosporins compared to 19 and 13 percent of those who chose penicillins.910 The dentists in our survey, however, were 61 vs. 38 percent in favor of penicillins over cephalosporins, including 24 percent th a t selected amoxi cillin specifically. Possibly, the dentists were combining the prophylactic regimens for prosthetic joint infections and bacterial endocarditis into one category. More likely, the debate in the dental literature has divided and confused the profession. Based on our results, argu ments about which antibiotic is most effective against oral
CLINICAL PRACTICE
bacteria vs. which is most effective against LPJI-causing bacteria are less im portant than the calibration of dental practitioners’ opinions against those of prim ary care providers, in this case orthopedic surgeons. In lieu of a comprehensive controlled study or an interdis ciplinary joint committee recom mendation, dentists must rely on other data to determine the need for chemoprophylaxis for these patients. In one study, researchers reviewed almost 2,700 hospital and dental records to investigate microorganisms associated w ith LPJI.20They concurred with the orthopedic surgeons th a t cephalosporins are indicated for dental patients with prosthetic joints. A cost-effectiveness analysis of 1 million hypothetical dental patients who had prosthetic joints suggested th a t no prophylaxis is a reasonable general policy.21 However, the authors recommended a one day oral cephalexin regimen for “high-risk” prosthetic patients. High-risk patients were defined in the article as individuals with previous complications of the prosthetic joint, including a history of infections, surgery and joint loosening; or, predis posing systemic illness including rheumatoid arthritis, diabetes mellitus or immunosupression while undergoing a dentally induced bacteremia for longer than 3 minutes. The authors suggested th a t an oral cephalexin strategy would decrease the risk of outcomes including death and am puta tions, compared to no prophylaxis. The use of penicillin was never determined as cost effective in this study. In the Howell and Green 434
JADA, Vol. 125, April 1994
survey, 32 percent of the surgeons recommended erythromycin as the alternative preferred drug, and 45 percent of the surgeons in our study concurred.9Fifty-seven percent of the dentists were also of th at opinion. Two other studies support the use of erythromycin to pre vent LPJI after dental treat-
Physicians and dentists agreed that patients who have had joint surgery should receive prophylactic antibiotics before dental treatment fo r the rem ainder of their lives. ment, although not necessarily as an alternate. The first was a cost-effectiveness analysis evaluating whether patients with artificial joints should take penicillin, erythromycin or no antibiotics before dental proce dures.13Although erythromycin is slightly more expensive, it was deemed the most costeffective prophylactic because it carries no risk of anaphylaxis. The second study reviewed almost 2,000 prosthetic hip replacement cases. The authors evaluated patients’ charts; microbiology laboratory reports on the 33 cases th a t became infected, of which only one could be associated with dental trea t ment; and the identity and drug sen Mr. Scarbrough is a research assistant, sitivities of the School of Dentistry, infecting Medical College of Georgia. organisms.11
Based on the drug sensitivities of the most common infecting organisms, the authors recommended erythromycin, clindamycin or a penas eresistant penicillin. CONCLUSION
Dentists and orthopedic surgeons in our survey agreed th a t dentists should consult with orthopedic surgeons before treating patients with major joint prostheses. They did not concur on a preferred drug for prophylaxis. However, considering the available data, opinions of the orthopedic surgery community and a lack of any study to the contrary, cephalosporins or erythromycin should be the primary prophylactic agent for dental patients who have prosthetic joints. Based on our survey results and review of the literature, we also recommend: ■** consultation with the patient’s orthopedic surgeon before any invasive dental treatm ent; ■ aggressive treatm ent of any dental infection in patients with prosthetic joints; *■ additional research to determine the relationship between dental treatm ent and LPJI; ■* development of guidelines by orthopedic surgeons and den tists for the dental management of patients with prosthetic joints. ■ The opinions expressedorimpliedare strictly those of the authors anddonot necessarilyreflect the opinionorofficial policies oftheAmericanDental Association. 1. PetersonLJ. Prostheticjoint infection anddental procedures. JADA1980;101:598600. 2. Downes EM . Late infectionaftertotal hip replacement. JBone Joint Surg 1977;59:42-4. 3. StinchfieldFE, Bigliani LU, Neu HC, Goss TP, Foster CG. Late hematogenous
CLINICAL PRACTICE
"YOUR FREE CATALOG KNOCKED MY SOCKS OFF" We get that sort of comment all the time. People are impressed that our free Consumer Information Catalog lists so many free and low-cost government booklets. There are more than 200 in all, containing a wealth of valuable information. They tell you how to make money, how to save money and how to invest it wisely. They tell you about federal benefits, housing, jobs, and learning activities for children. They fill you in on nutrition, health and much, much more. Our free Catalog will very likely impress you, too. But first you have to get it. Just send your name and address to:
Consumer Information Center Department KO Pueblo, Colorado 81009
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