United KingdomMayo Clinic study shows that dental procedures are not a risk factor in peri-prosthetic infections of the hip or knee. Authors call for reconsideration of administering antibiotics to all patients with prosthetic hip or knee joints who undergo dental treatment.
The full report can be found in broken link removed: https://www.lexi.com/individuals/dentistry/newsletters.jsp?id=march_10.
A report from the Mayo Clinic, published in January, described a large case-control study which examined the association between dental procedures - with or without antibiotic prophylaxis - and prosthetic joint infections.
The study found no increased risk of prosthetic joint infections after dental procedures. And to top that, the study found that antibiotic prophylaxis was not associated with any reduction in risk of infection. The study data indicated that there is no need for antibiotic prophylaxis in patients with total hip or knee replacements undergoing dental procedures.
This report comes on the heels of the recent information statement by the American Association of Orthopaedic Surgeons (AAOS) that advocated using antibiotic prophylaxis in all patients with a joint prosthesis. The Mayo Clinic study was designed to determine whether dental procedures, with and without antibiotic prophylaxis, are risk factors for prosthetic hip or knee infection. It was designed as a prospective study, case controlled, in a single-institution and conducted between 2001-2006.
There were 339 case patients and 339 control patients evaluated between December 2001 and May 2006. Case patients were those diagnosed with prosthetic hip or knee infections who were hospitalized at the Mayo Clinic. The control subjects were patients with prosthetic hips or knees with no infections, but who were hospitalized for:
Dental records were obtained from each patient's dentist. Dental procedures were categorized into low-risk and high-risk procedures:
Hip or knee infections were determined using routine microbiological techniques that isolated the bacterial flora.
The primary risk factor was whether a patient had a high risk or low risk dental procedure and whether, at the time of the procedure closest to the study date, the patient had antibiotic prophylaxis.
The risk factor was defined at 4 levels:
Results
The total numbers of patients enrolled in the study were 339 case patients with prosthetic hip or knee infections and 339 control patients with prosthetic hip or knee replacement but no infections.
There was no increased risk of prosthetic hip or knee infection for patients undergoing a high-risk or low-risk dental procedure who were not administered antibiotic prophylaxis compared with the risk for patients not undergoing a dental procedure.
The status of oral health was then compared between case patients and control patients during the 24 months that preceded the enrolment date. Among dentate case patients, the mean number of tooth brushings per week was 11.7 + 5.7 for case patients and 11.9 + 5.5 for control patients.
Statistically, it was determined that there was no difference in the risk of developing prosthetic hip or knee infection between a patient with at least 1 dental hygiene visit relative to a patient with no visits.
Among the 339 case patients, 259 (76%) had a diagnosis of prosthetic hip or knee infection established within 10 days before or after the study date. Staphylococci were the most commonly encountered organisms isolated from the infection sites. Thirty-five (13.5%) of the prosthetic hip or knee infection cases were associated with bacterial flora of potential oral or dental origin.
Low-risk and high-risk dental procedures performed within 6 months or 2 years of the hospital admission of infected prosthetic joints were not significantly associated with an increased risk of prosthetic hip or knee infection, compared with no dental procedure.
Odds ratio estimates were used to assess the effect of antibiotic prophylaxis on the risk of prosthetic joint infections. Low-risk and high-risk dental procedures with antibiotic prophylaxis were compared with the same risk procedure without prophylaxis. The estimate was 95% for low-risk procedures and 95% for high-risk procedures performed within 6 months of hospital admission. The estimate was 95% for low-risk procedures and 95% for high-risk procedures performed within 2 years before hospital admission date. These odd ratios and 95% confidence limit values indicated no significant differences between the risk of prosthetic joint infections with and without antibiotic prophylaxis.
The 35 patients with prosthetic hip or knee infection associated with dental flora pathogens were compared to a randomly selected group of 35 control patients. The data showed no increased risk of total hip or knee infection regardless of the use of antibiotic prophylaxis.
The study also addressed whether dental procedures were a risk factor for subsequent prosthetic hip or knee infections in patients who were immunocompromised, had diabetes, a prior arthroplasty, a duration of prosthetic joint infection symptoms of <8 days, or were within a year of joint arthroplasty. It was found that high-risk and low-risk dental procedures were not risk factors for prosthetic hip or knee infections in any of these subgroups.
Results Summary
Discussion Points
Oral Hygiene and Risk of Joint Infection
Poor dental hygiene, periodontal, and periapical infections probably produce bacteremia in the absence of dental procedures. In the Mayo Clinic study, the authors indicated that patients with >1 dental hygiene visit were 30% less likely to develop prosthetic hip or knee infection. The authors' suggested that the reported prosthetic joint infections attributed to dental procedures were more likely to have been caused by bacteremia related to routine daily activities than by bacteremia related to dental procedures
Accompanying Editorial to the Mayo Clinic Report
In the same issue of Clinical Infectious Diseases, there is an editorial entitled "Antibiotics for Prevention of Periprosthetic Joint Infection Following Dentistry: Time to Focus on Data," by W. Zimmerli and P. Sendi. This editorial made the following points:
The full report can be found in broken link removed: https://www.lexi.com/individuals/dentistry/newsletters.jsp?id=march_10.
A report from the Mayo Clinic, published in January, described a large case-control study which examined the association between dental procedures - with or without antibiotic prophylaxis - and prosthetic joint infections.
The study found no increased risk of prosthetic joint infections after dental procedures. And to top that, the study found that antibiotic prophylaxis was not associated with any reduction in risk of infection. The study data indicated that there is no need for antibiotic prophylaxis in patients with total hip or knee replacements undergoing dental procedures.
This report comes on the heels of the recent information statement by the American Association of Orthopaedic Surgeons (AAOS) that advocated using antibiotic prophylaxis in all patients with a joint prosthesis. The Mayo Clinic study was designed to determine whether dental procedures, with and without antibiotic prophylaxis, are risk factors for prosthetic hip or knee infection. It was designed as a prospective study, case controlled, in a single-institution and conducted between 2001-2006.
There were 339 case patients and 339 control patients evaluated between December 2001 and May 2006. Case patients were those diagnosed with prosthetic hip or knee infections who were hospitalized at the Mayo Clinic. The control subjects were patients with prosthetic hips or knees with no infections, but who were hospitalized for:
1) an arthroplasty of a different site or side of the index total hip or knee arthroplasty
2) for aseptic revision of the index arthroplasty
3) for other orthopaedic procedures
2) for aseptic revision of the index arthroplasty
3) for other orthopaedic procedures
Dental records were obtained from each patient's dentist. Dental procedures were categorized into low-risk and high-risk procedures:
1) Low-risk procedures included restorative dentistry, dental filling, endodontic treatment, and fluoride treatment.
2) High-risk procedures included dental hygiene, mouth surgery, periodontal treatment, dental extraction, and therapy for dental abscess.
2) High-risk procedures included dental hygiene, mouth surgery, periodontal treatment, dental extraction, and therapy for dental abscess.
Hip or knee infections were determined using routine microbiological techniques that isolated the bacterial flora.
The primary risk factor was whether a patient had a high risk or low risk dental procedure and whether, at the time of the procedure closest to the study date, the patient had antibiotic prophylaxis.
The risk factor was defined at 4 levels:
1) patient did not have dental procedure in the observation period (reference level)
2) was an edentulous patient, none of whom had a dental visit
3) patient had a dental procedure without antibiotic prophylaxis
4) patient had a dental procedure with antibiotic prophylaxis
2) was an edentulous patient, none of whom had a dental visit
3) patient had a dental procedure without antibiotic prophylaxis
4) patient had a dental procedure with antibiotic prophylaxis
Results
The total numbers of patients enrolled in the study were 339 case patients with prosthetic hip or knee infections and 339 control patients with prosthetic hip or knee replacement but no infections.
There was no increased risk of prosthetic hip or knee infection for patients undergoing a high-risk or low-risk dental procedure who were not administered antibiotic prophylaxis compared with the risk for patients not undergoing a dental procedure.
The status of oral health was then compared between case patients and control patients during the 24 months that preceded the enrolment date. Among dentate case patients, the mean number of tooth brushings per week was 11.7 + 5.7 for case patients and 11.9 + 5.5 for control patients.
Statistically, it was determined that there was no difference in the risk of developing prosthetic hip or knee infection between a patient with at least 1 dental hygiene visit relative to a patient with no visits.
Among the 339 case patients, 259 (76%) had a diagnosis of prosthetic hip or knee infection established within 10 days before or after the study date. Staphylococci were the most commonly encountered organisms isolated from the infection sites. Thirty-five (13.5%) of the prosthetic hip or knee infection cases were associated with bacterial flora of potential oral or dental origin.
Low-risk and high-risk dental procedures performed within 6 months or 2 years of the hospital admission of infected prosthetic joints were not significantly associated with an increased risk of prosthetic hip or knee infection, compared with no dental procedure.
Odds ratio estimates were used to assess the effect of antibiotic prophylaxis on the risk of prosthetic joint infections. Low-risk and high-risk dental procedures with antibiotic prophylaxis were compared with the same risk procedure without prophylaxis. The estimate was 95% for low-risk procedures and 95% for high-risk procedures performed within 6 months of hospital admission. The estimate was 95% for low-risk procedures and 95% for high-risk procedures performed within 2 years before hospital admission date. These odd ratios and 95% confidence limit values indicated no significant differences between the risk of prosthetic joint infections with and without antibiotic prophylaxis.
The 35 patients with prosthetic hip or knee infection associated with dental flora pathogens were compared to a randomly selected group of 35 control patients. The data showed no increased risk of total hip or knee infection regardless of the use of antibiotic prophylaxis.
The study also addressed whether dental procedures were a risk factor for subsequent prosthetic hip or knee infections in patients who were immunocompromised, had diabetes, a prior arthroplasty, a duration of prosthetic joint infection symptoms of <8 days, or were within a year of joint arthroplasty. It was found that high-risk and low-risk dental procedures were not risk factors for prosthetic hip or knee infections in any of these subgroups.
Results Summary
1. There was no increased risk of prosthetic hip or knee infection for patients undergoing a high-risk or low-risk dental procedure who were not administered antibiotic prophylaxis compared with the risk for patients not undergoing a dental procedure.
2. Antibiotic prophylaxis in high-risk or low-risk dental procedures did not decrease the risk of subsequent total hip or knee infection.
2. Antibiotic prophylaxis in high-risk or low-risk dental procedures did not decrease the risk of subsequent total hip or knee infection.
Discussion Points
1. The results of this large, prospective, case-controlled study at the Mayo Clinic showed that the use of antibiotic prophylaxis prior to dental procedures did not alter the subsequent risk of prosthetic hip or knee infection.
2. This Mayo Clinic study suggests that the risk of prosthetic hip or knee infection following dental procedures is not increased in those groups previously identified as being at risk.
3. The majority of prosthetic hip or knee infections are due to staphylococci. Bacterial species from dental procedures include viridians group streptococci, beta-hemolytic streptococci, and gram-positive anaerobes, species not ordinarily associated with prosthetic hip or knee infections.
2. This Mayo Clinic study suggests that the risk of prosthetic hip or knee infection following dental procedures is not increased in those groups previously identified as being at risk.
3. The majority of prosthetic hip or knee infections are due to staphylococci. Bacterial species from dental procedures include viridians group streptococci, beta-hemolytic streptococci, and gram-positive anaerobes, species not ordinarily associated with prosthetic hip or knee infections.
Oral Hygiene and Risk of Joint Infection
Poor dental hygiene, periodontal, and periapical infections probably produce bacteremia in the absence of dental procedures. In the Mayo Clinic study, the authors indicated that patients with >1 dental hygiene visit were 30% less likely to develop prosthetic hip or knee infection. The authors' suggested that the reported prosthetic joint infections attributed to dental procedures were more likely to have been caused by bacteremia related to routine daily activities than by bacteremia related to dental procedures
Accompanying Editorial to the Mayo Clinic Report
In the same issue of Clinical Infectious Diseases, there is an editorial entitled "Antibiotics for Prevention of Periprosthetic Joint Infection Following Dentistry: Time to Focus on Data," by W. Zimmerli and P. Sendi. This editorial made the following points:
1. Prosthetic joint infections occur in 0.3% to 1% of patients undergoing total hip arthroplasty and in 1% to 2% in patients after knee arthroplasty. Most of episodes are sequalea of Staphylococcus aureus sepsis, skin infection, or infections of the urinary tract.
2. Although it is conceivable that a small portion of the infections are caused by transient bacteraemia during dental procedures, clinical experience does not favour this hypothesis.
3. The consequences or prophylactic antibiotics are that
4. Clear conclusive data obtained from clinical studies can help in resolving the question of whom to premedicate with antibiotics.
5. This editorial reminds the physicians and the dental community that the Mayo Clinic study has the potential to reassure the responsible physicians and dentists that antibiotic prophylaxis is not needed for all patients with total joint replacement prior to any dental procedure and to convince individuals with joint replacement that meticulous dental hygiene is important.
2. Although it is conceivable that a small portion of the infections are caused by transient bacteraemia during dental procedures, clinical experience does not favour this hypothesis.
3. The consequences or prophylactic antibiotics are that
a) general prophylaxis increases the unjustified use of antibiotics
b) the risk of adverse effects (toxicity and allergy) will probably outweigh any prevention of prosthetic joint infection
c) the dentist could be sued for not giving antibiotics according to the AAOS guidelines
b) the risk of adverse effects (toxicity and allergy) will probably outweigh any prevention of prosthetic joint infection
c) the dentist could be sued for not giving antibiotics according to the AAOS guidelines
4. Clear conclusive data obtained from clinical studies can help in resolving the question of whom to premedicate with antibiotics.
5. This editorial reminds the physicians and the dental community that the Mayo Clinic study has the potential to reassure the responsible physicians and dentists that antibiotic prophylaxis is not needed for all patients with total joint replacement prior to any dental procedure and to convince individuals with joint replacement that meticulous dental hygiene is important.
