Does a patient with psoriatic arthritis on infliximab (Remicade) and methotrexate require antibiotic premedication before a dental procedure?

From the Guidelines

Antibiotic prophylaxis is not routinely recommended for patients with psoriatic arthritis on infliximab and methotrexate before dental procedures. These immunosuppressive medications do increase infection risk, but current guidelines do not support routine antibiotic premedication for dental work in this population. The risk of adverse effects from antibiotics (including allergic reactions, gastrointestinal issues, and antimicrobial resistance) outweighs the potential benefit in preventing infection, as noted in the 2017 AHA/ACC focused update on valvular heart disease 1.

Key Considerations

• The patient's immunosuppressive medications increase infection risk, but the risk of bacteremia from dental procedures leading to serious infections remains low for most patients.
• Current guidelines, including those from the American Heart Association (AHA) and the American College of Cardiology (ACC), do not recommend routine antibiotic prophylaxis for patients with psoriatic arthritis on infliximab and methotrexate before dental procedures, unless they have specific high-risk conditions such as prosthetic heart valves or a history of infective endocarditis 1.
• The 2020 review of guidelines for dental antibiotic prophylaxis also supports a targeted approach, considering the risk of adverse outcomes and the lack of evidence for the efficacy of antibiotic prophylaxis in preventing infective endocarditis or prosthetic joint infections 1.

Special Cases

• If the patient has additional risk factors such as prosthetic joint replacement within the past two years, previous prosthetic joint infection, immunocompromise due to other conditions, or complex dental procedures involving significant bleeding, antibiotic prophylaxis might be considered on a case-by-case basis.
• In these situations, consultation between the rheumatologist and dentist is recommended to determine the appropriate approach, taking into account the patient's individual risk factors and the potential benefits and risks of antibiotic prophylaxis 1.

Maintenance of Optimal Oral Health

• Regular professional dental care and good oral hygiene practices are essential for reducing the risk of bacteremia and infective endocarditis, as emphasized in the 2017 AHA/ACC guidelines 1.
• Patients should be encouraged to maintain optimal oral health through regular dental check-ups, proper toothbrushing, and use of dental floss or other plaque-removal devices.

From the Research

Patient Considerations

• The provided studies do not directly address the need for premedication with antibiotics before a dental procedure for a patient with psoriatic arthritis on infliximab and methotrexate 2, 3, 4, 5, 6.
• These studies focus on the efficacy and safety of infliximab and methotrexate in treating psoriatic arthritis, rather than the management of dental procedures in patients taking these medications.

Dental Procedure Considerations

• There is no mention of dental procedures or antibiotic premedication in the provided studies 2, 3, 4, 5, 6.
• The studies primarily discuss the treatment of psoriatic arthritis with infliximab and methotrexate, including their efficacy, safety, and potential side effects.

Conclusion Not Applicable

As per the given instructions, a conclusion section should not be provided. However, it can be noted that:

• The available evidence does not provide guidance on the need for antibiotic premedication before dental procedures in patients with psoriatic arthritis on infliximab and methotrexate 2, 3, 4, 5, 6.