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Dental Tribune Middle East & Africa Edition | September-October 2015 9mCME < Page 8 risk of adverse outcomes from IE and who would derive the greatest benefit from preven- tion. In patients with underlying cardiac conditions associated with the highest risk of adverse outcomes from IE, prophylaxis for some dental procedures is reasonable, even though we ac- knowledge that its effectiveness is unknown.”17 Therefore, the 2007 AHA guide- lines suggest that antibiotic prophylaxis should be consid- ered for patients presenting for treatment with the cardiac conditions identified in Table 2, and who are undergoing any dental procedure that involves the gingival tissues or peri- apical region of a tooth and for those procedures that perforate the oral mucosa. This would in- clude procedures such as biop- sies, suture removal, placement of orthodontic bands, and intra- ligamentary and intraosseous local anesthetic injections, but it does not include routine local anesthetic injections through noninfected tissue (Table 3). Antibiotic prophylaxis for prevention of delayed pros- thetic joint infection In 1997, the ADA and the Amer- ican Academy of Orthopedic Surgeons convened an expert panel of dentists, orthopedic surgeons and infectious disease specialists and published an Ad- visory Statement on Antibiotic Prophylaxis for dental patients with prosthetic joints.18 A 2003 advisory statement included some modifications of the clas- sification of patients at poten- tial risk and the stratification of bacteremic dental procedures (Table 4), but no changes in terms of suggested antibiotics or antibiotic regimens.19 An- tibiotic prophylaxis is not indi- cated for most dental patients with total joint replacements or for patients with pins, plates or screws. However, it is advised to consider antibiotic premedi- cation in a small number of pa- tients who may be at potential increased risk of experiencing hematogenous total joint infec- tion (Table 5). While bacteremias can cause hematogenous seeding of to- tal joint implants, it is likely that more oral bacteremias are spontaneously induced by rou- tine daily events than are den- tal treatment-induced. Patients who have undergone total joint arthroplasty should be encour- aged to perform effective daily oral hygiene procedures in order to maintain good oral health. The risk of bacteremia is much higher in a mouth with chronic inflammation than one that is healthy and well main- tained. Occasionally, a patient with a total joint prosthesis may pre- sent for dental treatment with a recommendation from his or her physician that is inconsist- ent with the current guidelines. In this case, the dentist is en- couraged to consult with the patient’s physician to discuss the nature of the needed dental treatment, to review the current guidelines regarding antibiotic prophylaxis and to determine if there are any special consid- erations that might affect the physician’s decision regarding antibiotic prophylaxis for the patient. After this consultation, the dentist may decide to fol- low the physician’s recommen- dation or, if in his or her pro- fessional judgment antibiotic prophylaxis is not indicated, de- cide to proceed with the needed dental treatment without anti- biotic prophylaxis. The dentist is ultimately responsible for making treatment decisions for his or her patient based on the dentist’s professional judgment. In February 2009, the AAOS published an information state- ment in which the organization, “recommends that clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bac- teremia.”20 In response to this statement, the American Acad- emy of Oral Medicine published a position paper in the June 2010 edition of the Journal of the American Dental Associa- tion.21 The authors of the AAOM posi- tion paper stated that they re- viewed the available literature on the subject as it relates to the AAOS 2009 information state- ment and concluded: “The risk of patients’ experiencing drug reactions or drug-resistant bac- terial infections and the cost of antibiotic medications alone do not justify the practice of using antibiotic prophylaxis in (all) patients with prosthetic joints.” The authors called for a future multidisciplinary, systematic review of the literature relating to antibiotic prophylaxis use in patients with prosthetic joints. In the meantime, they con- cluded that the new AAOS 2009 information statement20 should not replace the 2003 joint con- sensus statement.19 In December 2012, a panel of experts representing the Amer- ican Academy of Orthopedic Surgeons and the American Dental Association published a systematic review and clini- cal practice guideline, titled “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-based Guideline and Evidence Report.”23 This report contained the following three recommendations: “The practitioner might con- sider discontinuing the practice of routinely prescribing pro- phylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing den- tal procedures. “We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopedic implants undergoing dental procedures. “In the absence of reliable evi- dence linking poor oral health to prosthetic joint infections, it is the opinion of the work group that patients with prosthetic joint implants or other orthope- dic implants maintain appropri- ate oral hygiene.” The report also stated that the above recommendations “are not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mu- tual communication between patient, physician, dentist and other healthcare practitioners.” In 2014, a panel of experts con- vened by the American Dental Association Council on Scien- tific Affairs developed an evi- dence-based clinical practice guideline on the use of pro- phylactic antibiotics in patients with prosthetic joints who are undergoing dental procedures. This clinical practice guideline was published in The Journal of the American Dental As- sociation in January 2015 and contained the following recom- mendation: “In general, for patients with prosthetic joint implants, pro- phylactic antibiotics are not rec- ommended prior to dental pro- cedures to prevent prosthetic joint infection. The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk to 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 in- tegrated with the practitioner’s professional judgment and the patient’s needs and preferenc- es.”24 Summary Since their discovery eight decades ago, safe systemic an- tibiotics have revolutionized the treatment of infections, transforming once deadly dis- eases into manageable health problems. However, the grow- ing phenomenon of bacterial resistance, caused by the use and abuse of antibiotics and the simultaneous decline in re- search and development of new antimicrobial drugs, is now threatening to take us back to the pre-antibiotic era. Without effective treatment and preven- tion of bacterial infections, we also risk rolling back important achievements of modern medi- cine such as major surgery, or- gan transplantation and cancer chemotherapy.22 A fundamentally changed view of antibiotics is needed. They must be looked on as a com- mon good, where individuals must be aware that their choice to use an antibiotic will affect the possibility of effectively treating bacterial infections in other people. All antibiotic use, appropriate or not, “uses up” some of the effectiveness of that antibiotic, diminishing our abil- ity to use it in the future. For current and future generations to have access to effective pre- vention and treatment of bac- terial infections as part of their right to health, all of us need to act now. The window of oppor- tunity is rapidly closing.22 References 1. Health, United States, 2009: U.S. Department of Health and Human Services, Centers for Disease Control and Preven- tion, National Center for Health Statistics, 2009. 2. Health, United States, 2010: U.S. Department of Health and Human Services, Centers for Disease Control and Preven- tion, National Center for Health Statistics, April 2010. 3. Pallasch TJ. Pharmacology of Anxiety, Pain and Infection. In: Endodontics. 4th ed. Williams and Wilkins, Malvern, PA, 1994. 4. ADA Council on Scientific Affairs. Combating antibiotic resistance. J Am Dent Assoc 2004;135:484. 5. Nicolle L. Nosocomial In- fections. Gale Encyclopedia of Public Health. Macmillan Ref- erence USA, Farmington Hills, MI, 2002. 6. Sweeney LC, Jayshree D, Chambers PA, Heritage J. An- tibiotic resistance in general dental practice—a cause for concern. J Antimicrobial Chem- otherapy 2004;53:567. 7. Epstein JB, Chong S, Le ND. A survey of antibiotic use in dentistry. J Am Dent Assoc 2000;131:1600. 8. Associated Press. Killer su- perbug solution discovered in Norway. www.msnbc.com, De- cember 2009. 9. ADA Council on Scientific Af- fairs. Antibiotic use in dentistry. J Am Dent Assoc 1997;128:648. 10. Wills A. Why we learn from our mistakes. J Cognitive Neu- roscience 2007;19:1163. 11. Pallasch TJ. Antibiotic myths and reality. J Cali Dent Assoc 1986;14:65. 12. Baumgartner JC. Microbi- ology of Endodontic Disease. In: Endodontics. 6th ed. B.C. Decker Inc. Hamilton, Ontario, Canada, 2008. 13. Baumgartner JC, et al. Ex- perimentally induced infection by oral anaerobic microorgan- isms in a mouse model. Oral Microbiol Immunol 1992;7:253- 256. 14. Baumgartner JC, Xia T. An- tibiotic susceptibility of bacteria associated with endodontic ab- scesses. J Endodon 2003;29:44- 47. 15. Korzeniowski OM. Effects of antibiotics on the mammalian immune system. Infect Dis Clin NA 1989;3:469. 16. Hessen MT, Kaye D. Prin- ciples of selection and use of antimicrobial agents. Infect Dis Clin NA 1989;3:479. 17. Wilson W, Taubert K, et al. Prevention of Infective En- docarditis: Guidelines From the American Heart Asso- ciation, J Amer Heart Assoc 2007;116:1736-1754. 18. American Dental Associa- tion, American Academy of Or- thopaedic Surgeons. Advisory statement: Antibiotic prophy- laxis for dental patients with total joint replacements. J Amer Dent Assoc 1997;128;1004-1008. 19. American Dental Associa- tion, American Academy of Or- thopaedic Surgeons. Advisory statement: Antibiotic prophy- laxis for dental patients with total joint replacements. J Amer Dent Assoc 2003;134:895-898. 20. American Academy of Or- thopaedic Surgeons. Infor- mation statement: Antibiotic prophylaxis for bacteremia in patients with joint replace- ments. www.aaos.org. 2010. 21. Little JW, et al. The dental treatment of patients with joint replacements: A position paper from the American Academy of Oral Medicine. J Amer Dent As- soc 2010;141:667-671. 22. Cars, O. Meeting the chal- lenge of antibiotic resistance, BMJ 2008;337:726-728. 23. American Association of Orthopedic Surgeons and American Dental Association. Prevention of Orthopedic Im- plant Infections in Patients Un- dergoing Dental Procedures: Evidence-Based Guideline and Evidence Report. American Academy of Orthopedic Sur- geons. December 2012. 24. The Use of Prophylactic Antibiotics Prior to Dental Pro- cedures in Patients with Pros- thetic Joints: Evidence-Based Clinical Practice Guideline for Dental Practitioners – A Report of the American Dental Asso- ciation Council on Scientific Af- fairs. J Amer Dent Assoc 2015; 146(1):11-16. Editorial note: This article origi- nally appeared in ENDODON- TICS: Colleagues for Excellence, Winter 2012. Reprinted and updated with permission from the American Association of Endodontists, ©2012. The AAE clinical newsletter is available at www.aae.org/colleagues. Having taught future oral healthcare professionals at Loma Linda University School of Dentistry since 1965, Steven Morrow, DDS, MS, is currently a professor in the department of endodontics that he chaired from 1987 to 1990. He maintains responsibilities he accepted in 2000 as direc- tor of patient care services and clinical quality assurance. He was director, District VI, of the American Association of Endo- dontists from 1990 to 1993. He has also served as president of the Southern California Acad- emy of Endodontics and as presi- dent of the California State Asso- ciation of Endodontists. In1997,heearneddiplomatesta- tus from the American Board of Endodontics. Since 1998, he has been a fellow of the American College of Dentists; and since 2003, he has served on the edito- rial review board of the Journal of Endodontics. A life member of the American Dental Associa- tion, the American Association of Endodontists and the Califor- nia State Association of Endo- dontists, he is currently serving his second term as a member of the Dental Board of California. About the Author