Editor's note: Following this article's initial publication, the Michigan Antibiotic Resistance Reduction Coalition (MARR) provided some updates.
Chances are if you graduated from your dental program more than 10 years ago, the guidelines around antibiotic premedication have changed a time or two. You might even wonder whose guideline trumps whose, or which provider has the final say. Is it the orthopedist? The dentist? Heck, is it the patient?
When it comes to joint replacement, the confusion is valid. In 2014, the American Dental Association (ADA) Council on Scientific Affairs assembled an expert panel to conduct a systematic review stating, “for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to the dental procedure”1 But it wasn’t until 2016 that the American Academy of Orthopaedic Surgeons (AAOS) developed criteria saying, “the chance of oral bacteremia being related to joint infections is extremely low, with no evidence for association.” 2 So for two years, we sat in limbo between providers.
Thankfully both professional associations now mostly agree,3 but there are still providers who either haven’t gotten the message, don’t agree, or are so worried about being sued that they’ll keep writing prescriptions. I’ve heard many providers say, “Better safe than sorry” as they sign the prescription pad.
The importance of antibiotic stewardship
It’s estimated that there are at least 2.87 million antibiotic-resistant infections in the US, and 35,900 deaths a year that result from such infections.4 Dentists prescribe approximately 10% of all outpatient antibiotics in the US and are the top prescribers of clindamycin, the most common antibiotic leading to Clostridioides difficile (C. diff), which is no longer recommended for premedication. More than 80% of antibiotic prophylaxis prescribed by dentists was found to be unnecessary.5
You might also be interested in: Untangling current recommendations on antibiotic premedication
Antibiotic stewardship is gaining traction but still has a long way to go. We should no longer expect to leave the doctor with a Z-Pak, just in case. While the bugs are figuring out how to outwit the antibiotics, we are not creating new antibiotics to outwit them! Good stewardship promotes the appropriate use of antimicrobials, improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
When to premedicate
Appropriate antibiotic premedication has become the exception, not the rule. According to the ADA, there are relatively few patients and procedures for whom premedication might be indicated. They recognize extenuating circumstances, where the patient’s surgeon or treating physician makes the determination and prescription.6
Patients with joint replacement
- This applies only to patients with a history of complications with their joint replacement undergoing procedures that include gingival manipulation or mucosal incision. But even then, premedication should only be considered after consulting with their orthopedic surgeon—in other words, antibiotics wouldn’t necessarily be warranted after two years, for life, or another random other time frame—only in very specific instances.
- prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts
- prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords
- a history of infective endocarditis
- a cardiac transplant with valve regurgitation due to a structurally abnormal valve
- the following congenital (present from birth) types of heart disease:
- unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
- any repaired congenital heart defect with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or a prosthetic device
Key points for dental teams
- Follow the most updated guidance from the ADA.
- Dental procedures pose no greater risk for systemic bacteremia than activities of daily living, such as brushing teeth or eating.
- The use of antibiotic prophylaxis is not generally recommended for total joint replacement.
- Have patients verify penicillin allergies:
- <1% of the population is truly penicillin allergic
- If truly allergic (after verification), cephalexin, azithromycin, clarithromycin, or doxycycline can be used as alternatives.
- Check out tools created by OSAP/MARR for penicillin allergy reassessment8
- Do not prescribe clindamycin for patients who are allergic to penicillin or ampicillin
- Causes a more severe reaction such as C. diff
- Recommendations for antibiotic prophylaxis should be considered individually in each patient depending on their medical history.
Change is hard, especially when there’s a nagging what-if involved. But here’s a different what-if: what if instead of feeling like antibiotics were the answer for our high-risk patients, we educated them on the importance of a healthy oral microbiome? What if prior to a joint replacement or surgery, they got their mouths as healthy as possible? Then they’d understand why their dental care at home and in the office needs to be meticulous. Wouldn’t we be more successful in preventing a bacteremia by reducing the virulent bacteria in our patients’ mouths?
More information on antibiotic premedication
Are you still trying to understand when to prescribe or how to talk to patients and physicians about the change in recommendations? Check out the Michigan Antibiotic Resistance Reduction Coalition (MARR) website for excellent links to research, printables, literature, and more.
1. Sollecito T, Abt E, Lockhart P, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: evidence-based clinical practice guideline for dental practitioners — a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2015;146(1):11-16. doi:10.1016/j.adaj.2014.11.012
2. Management of patients undergoing dental procedures. Appropriate use criteria. September 23, 2016. https://www.aaos.org/globalassets/quality-and-practice-resources/dental/auc-patients-with-orthopaedic-implants-dental-procedures.pdf
3. Appropriate use criteria – care decision tree. https://www.aaos.org/globalassets/quality-and-practice-resources/dental/dental-prophylaxis-auc-decision-tree-v2_condensed_1.29.20-003.pdf
4. Dadgostar P. Antimicrobial resistance: implications and costs. Infect Drug Resist. 2019;12:3903-3910. doi:10.2147/IDR.S234610
5. Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Network Open. 2019;2(5):e193909. doi:10.1001/jamanetworkopen.2019.3909
6. Antibiotic stewardship. American Dental Association. September 2017. https://www.ada.org/en/resources/research/science-and-research-institute/oral-health-topics/antibiotic-stewardship
7. Wilson WR, Gewitz M, Lockhart PB, et al. Prevention of viridans group streptococcal infective endocarditis: a scientific statement from the American Heart Association. Circulation. 2021;143(20):e963-e978. doi:10.1161/cir.0000000000000969
8. Bailey E, Connell M, Fluent M, Kennedy E. Penicillin allergy assessment and medical referral to promote antibiotic stewardship. J Mich Dent Assoc. March 2022. https://www.mi-marr.org/documents/Bailey-MDA-Journal-March-2022-PCN-tool.pdf