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Joint Replacement Prophylaxis, American Dental Association 2014

ADA 2014 Expert panel recommendations.#

Adapted from Sollecito TP et al.

The 2014 Panel made the following clinical recommendation:

“In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. The practitioner and patient should consider 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. As part of the evidence-based approach to care, this clinical recommendation should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.”

Which joint(s) have been replaced?#

Total joint replacements that were of concern to dentistry were the major joints, such as the shoulder, elbow, hip, and knee.

Present guidelines DO NOT recommend antibiotic prophylaxis for patients with any type of joint replacement, pins, plates, or screws.

When was the last joint replaced?#

Previous guidelines (from 2003) recommended that antibiotic prophylaxis should be considered within the first 2 years after a total joint replacement, and beyond 2 years under [special circumstances][5] (see below). However, the ADA 2014 guidelines DO NOT RECOMMEND antibiotic prophylaxis prior to dental procedure.

Have you had any complications associated with the joint replacement?#

A history of prosthetic joint infections may still be a consideration for antibiotic prophylaxis before dental procedures.

Do you have any conditions (“special circumstances”) that would put you at a higher risk for hematogenous infections?#

Several comorbid diseases and conditions and special circumstances (see below) were thought to increase the risk for experiencing a hematogenous total joint infection. When these conditions were present, antibiotics was supposed to be considered. The ADA 2014 guidelines do not include any “special circumstances”. Professional judgement should prevail.

Patients at increased risk of developing hematogenous joint infection:#

  • All patients during the first two years after joint replacement.
  • Immunocompromised/immunosuppressed patients: Inflammatory arthropathies, such as rheumatoid arthritis and systemic lupus erythematosus.
  • Patients with comorbidities: Previous prosthetic joint infections, malnourishment, hemophilia, HIV infection, insulin dependent (type 1) diabetes, malignancy.

Do you have any drug allergies?#

Drug allergies may affect the choice of antibiotic used for prophylaxis.

Previous (ADA 2003 Guidelines) antibiotic prophylaxis for dental patients with total joint replacement:#

SituationAgentAdult Regimen
Standard general prophylaxisCephalexin, cephadrine, or amoxicillin2 g orally, 1 h before procedure
Unable to take oral medicationCephazolin or ampicillinCephazollin 1 g or ampicillin 2g IM or IV, 1 h before procedure
Allergic to penicillinClindamycin600 mg orally, 1 h before procedure
Allergic to penicillin and unable to take oral medicationClindamycin600 mg IV, within 30 min of procedure

Prescription for antibiotic prophylaxis for a patient at risk for infection due to a total joint replacement. 4 visits:#

Patients with no penicillin or amoxicillin allergies
Name: John Doe DOB: 1/1/50
Address:123 Main Street, Pleasantville, PA
Amoxicillin 500 mg tab.
Disp. 16 tabs.
Sig. 4 tabs. po, 1 hr. prior to dental appointment
Patients with cephalosporin or amoxicillin allergies
Name: John Doe DOB: 1/1/50
Address:123 Main Street, Pleasantville, PA
Clindamycin 300 mg tab.
Disp. 8 tabs.
Sig. 2 tabs. po, 30-60 min. prior to dental appointment