Antibiotic Prophylaxis Prior To Dental Procedures For The Prevention Of Prosthetic Joint Infections האם יש קשר בין טיפולי שיניים וזיהומים במפרקים אורתופדיים מלאכותיים? האם יש צורך במתן אנטיביוטיקה לפני טיפולי שיניים בחולים שעברו השתלת מפרק אורתופדי? מהם המינונים המומלצים? מהן ההמלצות למטופל?

1. Antibiotic Prophylaxis Prior
To Dental Procedures For
The Prevention Of
Prosthetic Joint Infections
Volfin Guy, Yarom Noam, Elad Sharon, Volpin Gershon
1

4. Volfin Guy, Yarom Noam, Elad Sharon, Volpin Gershon
The Journal of the Israeli Dental Association
.Apr;28(2):35-45, 74. Review. Hebrew 2011
Pub-Med indexed
4

5. Oral health & our body
• poor oral health (e.g. gum inflammation & teeth
decay) has a direct connection to a variety of body
illnesses
Endocarditis Diabetes
CVS diseases Cancer
& CHDs Mellitus
Pregnancy CVA RF
5 …and more

6. J.E.
Gegenral diagnosis
•68 years old, male
•Usually healthy
•Bone malignant tumor 1999, right femur
•Radiation + chemo + prosthetic joint
6

7. J.E.
Dental condition
•Teeth extracted
•Teeth decay
•Periodontal disease
•Bone loss
7

8. Oral health & orthopedics?
No recommendations yet from Israeli ministry of health
8

9. Oral health & orthopedics?
AAOS Information Statement: Antibiotic Prophylaxis for
Bacteremia in Patients with Joint Replacements
AAOM Position Paper:
The Dental Treatment Of Patients With Joint Replacements
9

10. Oral health & orthopedics?
AAOS and AAOM do NOT fully agree…
10

11. Oral health & orthopedics?
“…The ADA and AAOS do not have a joint
recommendation at this time.
There are differing opinions on the need for
antibiotic prophylaxis.”
11

12. Oral health & orthopedics?
Poor oral health leads to Prosthetic Joint Infection (PJI) ?
12

13. Oral health & orthopedics?
Dental procedures cause PJI ?
Will Antibiotic Prophylaxis help? Which Antibiotics? How much?
13

14. Oral health & orthopedics?
Good oral health + Dental procedures cause PJI ?
Do you still need Antibiotic Prophylaxis ?
14

15. Oral health & orthopedics?
Good oral health and PJI ?
15

16. Oral health & orthopedics?
• Should the orthopedic
surgeon & the dentist
consult each other?
• Should the orthopedic
surgeon talk about oral
health with the patient?
16

17. What’s in consensus?
•1,000,000 total joint
arthroplasties performed
annually
•7 percent are revision
procedures
17

18. What’s in consensus?
Prosthetic joint infection (PJI):
• a severe illness
• painful and discomforting
• damages the quality of life
• might be life-threatening
18

19. What’s in consensus?
• Staphylococcus Epidermidis &
Staphylococcus Aureus are the
common bacteria in PJI
• Staph. family are very rare inside
the mouth
19

20. What’s in consensus?
• Streptococci Viridans is common to
the mouth
(teeth decay, gum diseases)
• A relatively much lower percentage
of PJIs are caused by Streptococci
Viridans
20

21. What’s in consensus?
• Antibiotic prophylaxis is advisable where a risk of severe
infective complications exists.
21

22. What’s in consensus?
Antibiotic Toxicity
Antibiotic
Allergy
prophylaxis
Microbial Resistance
22

23. What’s in consensus?
• With gum disease, even tooth brushing, eating etc. causes
chronic bacteremia
23

24. What’s in consensus?
• Both orthopedics surgeons and dentists should consider
the possibility of PJI, consult each other and inform
their patients
• There is not enough knowledge up to date
24

25. What’s in consensus?
• Some dental treatments might
cause bacteremia
25

26. What’s NOT in consensus?
• ALL patients with prosthetic joints should be considered
candidates for PJI , therefore consider AP when undergoing
dental procedures
• That’s a life-time risk
26

27. What’s NOT in consensus?
• Is the mouth the source for the PJIs reported?
• Are ALL prosthetic joints are prone for PJI after a dental
treatment?
• Is this for life? Is this for each dental procedure?
• Is antibiotic prohylaxis always recommendend before each
dental treatment?
27

28. What’s NOT in consensus?
• Some dental treatments might cause
bacteremia, BUT NOT ALL
• Prosthetic Joint Infections are RARELY
caused by bacterial species common to the
mouth
• Evidence of a relationship between dental
procedures and PJIs is CIRCUMSTANTIAL
28

29. American Dental Association
• ADA + AHA joint paper (2007):
– dentists should reduce AP for prevention of Endocarditis
by 90%
(compared to previous recommendations)
– widespread use of antibiotics = a significant increase of
drug-resistant bacterial infections
29

30. American Dental Association
• ADA + AHA joint paper (2007):
– Daily bacteremia is even caused when brushing, eating
etc.
30

31. Conclusions
to g
i
?ant ve or no
ibiot t
ic pr to give
op h y
l a xi s
31

32. Conclusions
High risk patients
&
High risk dental Procedures
(bacteremia)
Antibiotic Prophylaxis
Antibiotic Prophylaxis Maintain good
Maintain good
1h before
1h before oral health
oral health
dental procedure
dental procedure
32

33. I. High Risk of Prosthetic Joint Infection *
• Immunocompromised / immunosuppressed
• Inflammatory arthropathies (rheumatoid arthritis, SLE etc.)
• Previous PJIs
• less than 2 years after the prosthetic joint replacement
• co-morbidities (e.g.: diabetes, obesity, HIV, smoking,
Malnourishment, Hemophilia, Malignancy etc.)
• poor oral health (e.g.: periodontitis, gingivitis, abscesses,
osteomyelitis etc.)
33 * Volfin G et al: The use of antibiotic prophylaxis prior to dental procedures for the prevention
of prosthetic joint infection: Refuat Hapeh Vehashinayim. 2011 Apr;28(2):35-45, 74. Review.
Hebrew. Pub-med indexed

34. II. Dental procedures with HIGH risk for
prosthetic joint Infection *
• ALL PROCEDURES THAT DAMAGE THE ORAL TISSUES,
CAUSING BLEEDING & BACTEREMIA
34 * Based on the ADA Report, Antibiotic prophylaxis for dental patients with total
joint replacements. J Am Dent Assoc. 2003;134(7):895-898

35. Give antibiotic prophylaxis ?
•Dental fillings
•Dental crowns
•Porcelain laminates
•X-rays, dental CT
35

36. Give antibiotic prophylaxis ?
•Root canal treatments
•Orthodontic treatment
•Dental anesthesia
Only if Periodontal
Ligament (PDL)
is damaged
36

37. Give antibiotic prophylaxis ?
Surgery:
•Extractions
•Dental implants, Bone implantations
•Sinus lift
•Stitches removal
37

38. Give antibiotic prophylaxis ?
Periodontal disease / inflammation
Periodontal treatment
38

39. Give antibiotic prophylaxis ?
Periodontal Abscess drainage
39

40. Give antibiotic prophylaxis ?
40

41. III. Antibiotic Prophylaxis *
Only if prescribed, only for high risk patients,
to swallow (PO) 1 hour before high risk dental procedures
Penicillin 2 gr
Amoxicillin, Ampicillin
Cephalosporins
Cephalexin , Cefadroxil 2 gr
* Not safe for severe penicillin allergy
41

42. III. Antibiotic Prophylaxis *
Only if prescribed, only for high risk patients,
to swallow (PO) 1 hour before high risk dental procedures
Lincosamides
Clindamycin / Dalacin C 600 mg
* pregnant=ok, breast-feeding = not safe
Macrolides 500 mg
Azithromycin, Clarithromycin
42 * Based on the ADA Report, Antibiotic prophylaxis for dental patients with total
joint replacements. J Am Dent Assoc. 2003;134(7):895-898

43. IV. Recommendations for orthopedics *
• Inform
Inform the patient & dentist
before elective joint replacement
that poor oral health is a possible
risk for PJI.
43 * Volfin G et al: The use of antibiotic prophylaxis prior to dental procedures for the prevention
of prosthetic joint infection: Refuat Hapeh Vehashinayim. 2011 Apr;28(2):35-45, 74. Review.
Hebrew. Pub-med indexed

44. IV. Recommendations for orthopedics *
• Refer
Refer your patient to the dental
surgeon before joint surgery
44 * Volfin G et al: The use of antibiotic prophylaxis prior to dental procedures for the prevention
of prosthetic joint infection: Refuat Hapeh Vehashinayim. 2011 Apr;28(2):35-45, 74. Review.
Hebrew. Pub-med indexed

45. IV. Recommendations for orthopedics *
• Postpone
postpone any elective joint
replacement until completing
necessary dental procedures
even for a few weeks or months
45 * Volfin G et al: The use of antibiotic prophylaxis prior to dental procedures for the prevention
of prosthetic joint infection: Refuat Hapeh Vehashinayim. 2011 Apr;28(2):35-45, 74. Review.
Hebrew. Pub-med indexed

46. IV. Recommendations for orthopedics *
• Add in your discharge summary:
In each future dental treatment,
the dentist should consider AP in
order to prevent LPJI
46 * Volfin G et al: The use of antibiotic prophylaxis prior to dental procedures for the prevention
of prosthetic joint infection: Refuat Hapeh Vehashinayim. 2011 Apr;28(2):35-45, 74. Review.
Hebrew. Pub-med indexed

47. IV. Recommendations for orthopedics *
• Recommend your patients:
– regular visits in the dental clinic
every 3 months
– dental and gingival maintenance
(home & clinic)
– treat immediately any sign of
infection
47 * Volfin G et al: The use of antibiotic prophylaxis prior to dental procedures for the prevention
of prosthetic joint infection: Refuat Hapeh Vehashinayim. 2011 Apr;28(2):35-45, 74. Review.
Hebrew. Pub-med indexed

48. J.E.
•Never received antibiotic prophylaxis prior to
dental treatment…
•Was never informed by the dentist or by the
orthopedic surgeon of any possible connection…
Excu
Excus
se
e
…In me for
…Inf me for n
formi
ormin no
ng yo ot
g you t
u
48

49. J.E.
Current status
•2 gr. Moxypen po 1h before dental bacteremia
•Periodontal maintenance every 3 months
•Extractions + dental implants + bone implants
•Crowns + root canals + fillings
•Perfect OH
49

50. Lets work together …
Orthopedic Dental Prevention of
Surgeon Surgeon Prosthetic Joint
Infection
50

51. Lets work together …
our
or Y
ks F ion !
Than ent
Att
dr.guy.volfin @ gmail . com
www.dr-guy.com