Hamedani Sh. J Dent Shiraz Univ Med Scien 2013; 14(1): 49-52 A Letter to the Editor A Clinical Practice Update on the Latest AAOS/ADA Guideline (December 2012) on Prevention of Orthopaedic Implant Infection in Dental Patients Hamedani Sh. DDS, MSc Private Practice, Shiraz, Iran KEY WORDS ABSTRACT Guideline; The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Prostheses and Implants; Association (ADA), along with 10 other academic associations and societies recently American Dental (December 2012) published their mutual clinical practice guideline “Prevention of Or- Association; thopaedic Implant Infection in Patients Undergoing Dental Procedures.” This evi- Antibiotic Prophylaxis dence-based guideline ,detailed in 325 pages, has three recommendations and substitutes the previous AAOS guideline. The new published clinical guideline is a protocol to pre- vent patients undertaking dental procedures from orthopaedic implant infection. The guideline is developed on the basis of a collaborative systematic review to provide practi- cal advice for training clinicians, dentists and any qualified physicians who need to con- sider prevention of orthopaedic implant (prosthesis) infection in their patients. This sys- tematic review found no explicit evidence of cause-and-effect relationship between den- tal procedures and periprosthetic joint infection (PJI). This LTTE wishes to present a vivid summary of AAOS/ADA clinical practice guideline as a clinical update and an academic implementation to inform and assist Iranian compe- tent clinicians and dentists in the course of their treatment decisions, to enrich the value and quality of health care on the latest international basis. Corresponding author: Hamedani Sh., School of Dentistry, Shiraz University of Medical Sciences, Shiraz, IRAN Tel: +98-711-6280458 Email: [email protected] Cite this article as: Hamedani Sh. A Clinical Practice Update on The Latest AAOS/ADA Guideline (December 2012) on Prevention of Orthopaedic Implant Infection in Dental Patients. Journal of Dentistry Shiraz University of Medical Sciences 2013; 14(1): 49-52. “Evidence Insufficient to Recommend Prophylactic reviews and clinical practice guidelines. The full guide- Antibiotics for Dental Patients with Orthopaedic Im- line presents a comprehensive systematic review of plants.” was one of the smashing headlines of the dental available evidence directing on the prevention of ortho- updates in the winter 2013 [4-7]. paedic implant(OI) infection in patients receiving dental The American Academy of Orthopaedic Surgeons procedures [1]. (AAOS) and the American Dental Association (ADA), Jevsevar (Chairman of AAOS group) and Abt (on along with 10 other academic associations and societies behalf of ADA group) [3] published an editorial to this recently (December 2012) published their mutual clini- guideline and described how the recommendations have cal practice guideline “Prevention of Orthopaedic been evidence-based. They believe that antibiotic pro- Implant Infection in Patients Undergoing Dental phylaxis recommendations, in the 2009 AAOS informa- Procedures” [1, 3]. tion statement, can only be regarded as an educational This 325-page evidence-based guideline has three aid and not as an official guideline [3]. recommendations and substitutes the previous AAOS guideline. The new clinical practice guideline was es- SYNOPSIS OF THE NEW GUIDELINE tablished using the published AAOS CPG (Clinical The workgroup, initially developed three recommenda- Practice Guideline) development process and also con- tions for antibiotic prophylaxis in dental patients with sidering all the standards recommended for systematic joint replacements. These recommendations shaped the 49 A Clinical Practice Update on the Latest AAOS/ADA Guideline (December 2012) on Prevention of … Hamedani Sh. Figure 1 A print screen, copy image of the AAOS website to access the new guideline: http://www.aaos.org/research/guidelines/PUDP/ dental_guideline.asp basic foundation for systematic reviews of the literature Recommendation 1. regarding the dental procedures and periprosthetic joint “The practitioner might consider discontinuing the infection (PJI). The workgroup also determined detailed practice of routinely prescribing prophylactic anti- criteria for quality appraisal of the published data and biotics for patients with hip and knee prosthetic joint consequently avoiding any bias. To avoid bias, the AA- implants undergoing dental procedures.” [1]. OS uses specific words for its recommendations and Being graded as Limited, this recommendation is gives rationals for their usage. Due to the limitations in based on limited evidence and depicts that dental proce- available evidence, the three recommendations presente- dures are not related to OI infection. Moreover, it indi- d in the new guideline are classified as limited, incon- cates that practitioners should consider changing their clusive and consensus with one recommendation for customary practice of prescribing prophylactic antibiot- each grade of evidence. Higher grade recommendations ics for dental patients [1, 5-7]. The phrase limited is are comparatively rare within published CPGs. The definitive; which means low levels of evidence is pre- work team emphasized that they did not suppose this sent to support the recommendation. Practitioners new guideline to be an impartial document. All three should be alert to up-coming publications that hold evi- recommendations should be integrated into the deci- dence and their decisions should reflect their individual sion-making process to improve patient care. The guide- judgment and the patient’s preferences [1]. line accentuates on the collaboration between the physi- Stronger evidences support this recommendation cians, dentists and patients to plan a treatment based on compared to other two recommendations: the evidence, clinical findings and patient preferences I. Clinical practitioners believe in changing their long- [1-3]. The following guideline is a summary of the AA- standing tradition in the prescription of prophylactic OS-ADA recommendations for prevention of OI infec- antibiotics for dental patients. tion in patients receiving procedural dental treatments. II. The evidences indicate that dental procedures are not 50 Hamedani Sh. J Dent Shiraz Univ Med Scien 2013; 14(1): 49-52 linked to the OI infections. emphasizes on the imperative role of patients’ prefer- III. The risk of OI infections is not reduced by the pre- ence in decision making and also affirms the flexibility procedural antibiotic prophylaxis. of practitioners in deciding whether to follow a recom- IV. Strong evidence indicates that pre-procedural anti- mendation rated as Consensus or not. Consensus rec- biotic prophylaxis reduces the incidence of bac- ommendations are the weakest form of recommendation teremia induced by post dental procedure. and cannot be used to ignore recommendations devel- V. No evidence proves that bacteremia increases the oped from higher levels of evidence [1-3]. risk of OI infections [1, 3, 5]. This recommendation conveys the maintenance of good oral hygiene and apparently, it is the only consen- Recommendation 2. sus recommendation in the new guideline. Oral hygiene “The work group was unable to recommend for or measures are available and cheap, provide possible against the use of topical oral antimicrobials in pa- benefit, are consistent with current clinical practice and tients with prosthetic joint implants or other ortho- are in concordance with good oral health [3]. paedic implants undergoing dental procedures.” [1] This recommendation is graded as Inconclusive, Goals and Implications for Clinical Practice regarding the strength of the evidence. The guidelines The rate of OI infection is recorded from 0.3% to 8.3% implies that practitioners should consider a little con- in the available published literature. Invasion of organ- straint in their decision that whether to follow an incon- isms into the surgical wound during the surgery, ha- clusive recommendation or not. The guideline empha- ematogenous spread, recurrence of infection in previ- sizes that patient preference should have a significant ously involved and infected joints, or propagation from influencing role and practitioners should cautiously wait an infective local source may produce such infection for future publications that elucidate the existing evi- [1]. dence to determine the balance between benefits and Established on the best existing evidence, the ra- potential risk [1, 2, 4]. tional for this clinical practice guideline is to assist the Apparently, this recommendation refers to the ap- related clinicians and dentists to choose a paramount plication of oral topical antimicrobials in the prevention preventing and treatment modality when it is requisite. of OI infections in dental patients. It indicates that there Contemporary dental practice inevitably depends on is no direct evidence to confirm that application of oral evidence-based standards and stipulates physicians and topical antiseptics (before dental procedures) would dentists to employ the best available evidence for treat- reduce bacteremia and hence prevent OI infections [5]. ment planning in their clinical practice. That’s why this The guideline points out the followings as the examples guideline consists a systematic review of literature, con- of topical antiseptics administered by dentists: Chlor- ducted between October 2010 and July 2011 by AAOS hexidine Gluconate oral rinse, povidone-iodine mouth and ADA methodologists and the doctor/dentist voca- rinse, hydrogen peroxide mouth rinse and mouth rinses tional groups and declared wherever the evidence was with sodium-p-toluene (chloramine-T) [1-3, 5]. adequate or inadequate .They even discussed the gaps in the literature, where future researches are particularly Recommendation 3 needed [1]. “In the absence of reliable evidence linking poor oral Jevsevar, an orthopaedic surgeon and chairman of health to prosthetic joint infection, it is the opinion of the AAOS team, declared that this clinical practice the work group that patients with prosthetic joint guideline was not supposed to be an impartial document implants or other orthopaedic implants maintain and he confirmed that clinicians should use it as an in- appropriate oral hygiene.” [1] structive tool in their treatment planning to improve the This recommendation was graded as Consensus, quality and efficacy of their health care [3]. indicating that expert opinion supports the guideline In summary, the guideline is deliberated to con- recommendation albeit the fact that no available evi- duct clinical practice and also to provide a source of dence can encounter the inclusion criteria. The guideline information for all qualified practitioners dealing with 51 A Clinical Practice Update on the Latest AAOS/ADA Guideline (December 2012) on Prevention of … Hamedani Sh. prevention of OI infection in dental patients. The AAOS DentalSummofRec.pdf. Accessed (1.18.2013) and ADA hope that this guideline would also assist to 4. Dental Editorial: David S. Jevsevar and Elliot Abt, ensure patients regarding the logics behind their treat- “The New AAOS/ADA Clinical Practice Guide- ment planning [1]. lines on Prevention of Orthopaedic Implant Infec- Therefore, The new guideline replaces the previ- tion In Patients Undergoing Dental Procedures”. ous AAOS Information Statement and the full guide- Available at: http://www.aaos.org/research/ guide- line with all succeeding credentials and workgroup dec- lines/PUDP/dentaleditorial.pdf.Accessed(1.18.201). larations is available to access on the AAOS website: 5. Lexicomp Newsletter : Guideline update on antibi- http://www.aaos.org/research/guidelines/PUDP/PUDP_ otic prophylaxis for joint replacement patients (De- guideline.pdf and the ADA website: http://www.ada. cember 2012):Accessed on (1.18.2013). org/sections/professionalResources/pdfs/PUDP_guideli 6. Guideline: Antibiotics Need Not be Routine for ne.pdf (Figure1). Dental Work. Medscape. Dec 21, 2012. Accessed (1.18.2013). Webliography 7. AAOS Online Newsroom: Evidence Insufficient to 1. American Academy of Orthopaedic Surgeons and Recommend Routine Antibiotics for Joint Re- the American Dental Association Prevention of Or- placement Patients Who Undergo Dental Proce- thopaedic Implant Infection in Patients Undergoing dures. 2013, Accessed (1.18.2013), http:// news- Dental Procedures Guideline. Rosemont (IL): room.aaos.org/media-resources/Press-releases/evid- AAOS: 2012. Accessed (1.18.2013). ence-insufficient-to-recommend-routine-antibiotics- 2. A summary of the recommendations of the AAOS- for-joint-replacement-patients-who-undergo-dental- ADA clinical practice guideline, Prevention of Or- procedures.htm#rel thopaedic Implant Infection in Patients Undergoing 8. AAOS, ADA Release CPG for Prophylactic Antibi- Dental Procedures. Available at: otics, 2013, 1.18.2013, Available on: http://www. http://www.aaos.org/research/guidelines/PUDP/ aaos.org/news/aaosnow/jan13/cover1.asp 52