Antibiotic prophylaxis and invasive dental treatment in prosthetic joint patients

To describe current clinical practice among specialist orthopaedic surgeons in New Zealand in their recommendations regarding antibiotic prophylaxis for patients with prosthetic joints who undergo invasive dental treatment.

Data was collected from a single wave postal survey of all practicing orthopaedic surgeons in New Zealand. Literature review was performed using web-based online search engines and library resources.

The response rate from the surgeons was high (75%). Almost 94% of respondents recommended antibiotic prophylaxis for prosthetic joint patients prior to invasive dental treatment as a general principle and 90% of respondents considered that antibiotic prophylaxis was necessary as long as there was a prosthetic joint in situ. The majority of clinicians follow the AHA guidelines; that is, a single preoperative oral dose of 2 g amoxicillin or 600 mg clindamycin if the patient was allergic to penicillin. Over half did not recommend a 6-hour postoperative dose. Patients with medical conditions placing them "at-risk" of prosthetic joint infection were correctly identified by most orthopaedic surgeons especially those with diabetes and other forms of immunosuppression. The setting in which dental surgery was performed was not seen as being important. No randomised controlled trials were identified and currently no definite scientific evidence exists for the systematic use of prophylactic antibiotics before dental procedures in patients with prosthetic joints. In view of the high clinical cost of bacterial infection in cardiac and prosthetic joint patients, most guidelines currently favour the use of prophylactic antibiotics before invasive dental procedures in all patients within 2 years of the index surgery and high risk patients for the rest of their life.

In the absence of level 1 evidence for or against the use of prophylactic antibiotics in patients with prosthetic joints undergoing invasive dental treatment, the most recent ADA/AAOS guidelines provide the best available advice for dental practitioners and their patients. Further discussion between orthopaedic surgeons, general medical practitioners and dental practitioners should be encouraged in order to reach a consensus in New Zealand over this controversial issue.