Sir,,
We read this editorial with interest. The authors aptly comment on the lack of evidence
either to link prosthetic joint infections to dental procedures or to show
that antibiotic prophylaxis is effective. A recent incident in our
clinical practice has highlighted this contentious issue again.
An 84-year-old lady had always been prescribed antibiotics prior to
dental procedures (typically once a year) to reduce the risk of infection
of her primary total knee arthroplasty (TKA), implanted 17 years ago. At
her most recent dental appointment for a routine 'scale and polish', her
dentist decided not to cover with prophylactic antibiotics in accordance
with the lack of support for their use. There was no evidence of an active
dental infection at the time and she was otherwise medically fit with no
risk factors for infection. She then presented to our orthopaedic team
four days later, having developed pain, swelling, warmth and restricted
range of movement in her replaced knee. Clinical examination revealed
signs consistent with an infection. X-rays did not show any signs of
implant failure or loosening and serological analysis showed raised
inflammatory markers. Knee aspiration and arthroscopic washout were
performed, and microbiological culture grew Streptococcus viridans, a known
mucosal commensal organism,1 supporting possible haematogenous
dissemination during her dental procedure as a cause of infection. This
was followed by antibiotic treatment and her symptoms have since settled
with apparent full recovery.
Despite the evidence, or rather the lack thereof, it was very hard to
contest her own belief that had she been given antibiotic prophylaxis as
usual she would not have developed this infection.
The Working Party of British Society for Antimicrobial Chemotherapy
documented in 1992 the lack of evidence to support the use of antibiotic
prophylaxis before dental procedures in patients with joint replacements,2 and this recent editorial in response to a very thorough review3 of the literature is in agreement.
The American Academy of Orthopaedic Surgeons and the American Dental
Association in their joint Advisory Statement (2003) suggest that such
prophylaxis should be considered in patients with higher risk of a
haematogenous infection undergoing procedures with a higher bacteraemic
risk, although they do suggest practitioners should exercise their own
clinical judgment.4
We therefore believe that national guidelines, as per those for
prophylaxis against infective endocarditis5 endorsed by both the
British Orthopaedic Association and the British Dental Association, need to
become available, which would be of great benefit to both orthopaedic
surgeons and dental practitioners. These will allow best practice, and be
of benefit with regards to potential litigation and conflict between
colleagues or patients.
K.I. Eleftheriou,
Orthopaedic Specialist Registrar,
L. Parker, SpR Orthopaedics,
J. Kitson, Consultant Orthopaedic Surgeon,
Queen Elizabeth II Hospital,
Hertfordshire, UK.
1. Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defining the normal bacterial flora of the oral
cavity. J Clin Microbiol 2005;43:5721-32.
2. Simmons NA, Ball AP, Cawson RA, et al. Case against antibiotic prophylaxis for
dental treatment of patients with joint prostheses. Lancet 1992;339:301.
3. Uckay I, Pittet D, Bernard L, et al. Antibiotic prophylaxis before invasive dental
procedures in patients with arthroplasties of the hip and knee. J Bone
Joint Surg [Br] 2008;90-B:833-8.
4. American Dental Association; American Academy of Orthopaedic Surgeons. Antibiotic prophylaxis for dental patients with total joint
replacements. J Am Dent Assoc 2003;134:895-9.
5. Richey R, Wray D, Stokes T; Guideline Development Group. Prophylaxis against infective
endocarditis: summary of NICE guidance. BMJ 2008;336:770-1.
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