What is the American Dental Association (ADA) and American Academy of Orthopaedic Surgeons (AAOS) statement on the use of antibiotics for dental procedures?

From the Guidelines

The American Dental Association (ADA) and American Academy of Orthopaedic Surgeons (AAOS) no longer recommend routine antibiotic prophylaxis before dental procedures for patients with prosthetic joint implants, except for a small subset of patients at highest risk, as stated in the 2017 guidelines 1.

Key Points

• The ADA and AAOS recommend antibiotic prophylaxis only for patients with a history of prosthetic joint infections, immunocompromised patients, and those within the first two years after joint replacement surgery with additional risk factors like diabetes or rheumatoid arthritis.
• The typical regimen for antibiotic prophylaxis is amoxicillin 2g orally one hour before the dental procedure, or azithromycin for penicillin-allergic patients, as recommended in the 2017 guidelines 1.
• The change in recommendation is based on research showing that the risks of antibiotic use, including allergic reactions, antibiotic resistance, and C. difficile infections, outweigh the benefits for most patients.
• Studies have consistently shown that dental procedures do not significantly increase the risk of prosthetic joint infections in most patients, with bacteremia from routine daily activities like brushing teeth being more common than from dental procedures 1.

Evidence-Based Recommendations

• The 2017 guidelines from the AAOS and ADA emphasize the importance of individual patient risk assessment and collaboration between dentists and orthopedic surgeons 1.
• Maintaining good oral hygiene remains essential for all patients with joint replacements, as stated in the 2015 guidelines from the ADA 1.
• The use of antibiotic prophylaxis should be limited to patients at highest risk, as the benefits of antibiotic use do not outweigh the risks for most patients, according to a study published in 2020 1.

From the Research

American Dental Association (ADA) and American Academy of Orthopaedic Surgeons (AAOS) Statement

• The ADA and AAOS have issued statements regarding the use of antibiotics for dental procedures in patients with prosthetic joints 2, 3.
• The 1997 advisory statement by the ADA and AAOS suggested prophylaxis for "high risk" patients, recommending a single dose of amoxicillin, cephradine, or clindamycin when prophylaxis is selected 2.
• However, the 2015 evidence-based clinical practice guideline developed by the ADA Council on Scientific Affairs recommends that prophylactic antibiotics are not indicated for patients with prosthetic joint implants prior to dental procedures to prevent prosthetic joint infection 3.

Recommendations and Guidelines

• The ADA and AAOS recommend considering possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use 3.
• A 2020 survey found that dentists' recommendations for the use of antibiotic prophylaxis varied depending on different factors, including health status of the patient, dental procedure, and time elapsed since joint surgery, suggesting that adherence to the ADA guidelines is still challenging 4.
• The American Academy of Oral Medicine has also issued a position paper stating that the risk of patients' experiencing drug reactions or drug-resistant bacterial infections and the cost of antibiotic medications alone do not justify the practice of using antibiotic prophylaxis in patients with prosthetic joints 5.

Effectiveness of Antibiotic Prophylaxis

• A 2021 systematic review found that lower extremity prosthetic joint infection associated with dental procedures is often caused by organisms unlikely to be prevented with amoxicillin, and that additional studies are warranted to determine the choice and efficacy of antibiotic prophylaxis to prevent dental-associated prosthetic joint infection in high-risk patients 6.
• The review also found that an estimated 46% of organisms may be resistant to amoxicillin, highlighting the need for further research on the effectiveness of antibiotic prophylaxis in preventing prosthetic joint infection 6.