Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

325 Pages·2012·3.36 MB·English

by  Kevin Boyer

PREVENTION OF ORTHOPAEDIC IMPLANT
INFECTION IN PATIENTS UNDERGOING DENTAL
PROCEDURES

EVIDENCE-BASED
GUIDELINE
AND EVIDENCE REPORT

AAOS Clinical Practice Guideline Unit 1 v0.2 2.2.2012
Disclaimer
This clinical guideline was developed by a physician and dentist volunteer Work Group
and experts in systematic reviews. It is provided as an educational tool based on an
assessment of the current scientific and clinical information and accepted approaches to
treatment. The recommendations in this guideline are not intended to be a fixed protocol
as some patients may require more or less treatment or different means of diagnosis.
Patients seen in clinical practice may not be the same as those found in a clinical trial.
Patient care and treatment should always be based on a clinician’s independent medical
judgment given the individual clinical circumstances.
Disclosure Requirement
In accordance with AAOS policy, all individuals whose names appear as authors or
contributors to this clinical practice guideline filed a disclosure statement as part of the
submission process. All panel members provided full disclosure of potential conflicts of
interest prior to beginning work on the recommendations contained within this clinical
practice guideline.
Funding Source
No funding from outside commercial sources to support the development of this
document.
FDA Clearance
Some drugs or medical devices referenced or described in this clinical practice guideline
may not have been cleared by the Food and Drug Administration (FDA) or may have
been cleared for a specific use only. The FDA has stated that it is the responsibility of the
physician to determine the FDA clearance status of each drug or device he or she wishes
to use in clinical practice.
Copyright
All rights reserved. No part of this clinical practice guideline may be reproduced, stored
in a retrieval system, or transmitted, in any form, or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior written permission
from the AAOS.

Published 2012 by the American Academy of Orthopaedic Surgeons
6300 North River Road
Rosemont, IL 60018
First Edition
Copyright 2012 by the American Academy of Orthopaedic Surgeons & American Dental
Association
AAOS Clinical Practice Guideline Unit 2 v0.2 2.2.2012
Summary of Recommendations
The following is a summary of the recommendations of the AAOS-ADA clinical practice
guideline, Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental
Procedures. This summary does not contain rationales that explain how and why these
recommendations were developed, nor does it contain the evidence supporting these
recommendations. All readers of this summary are strongly urged to consult the full
guideline and evidence report for this information. We are confident that those who read
the full guideline and evidence report will see that the recommendations were developed
using systematic evidence-based processes designed to combat bias, enhance
transparency, and promote reproducibility.
This summary of recommendations is 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 mutual communication between
patient, physician, dentist and other healthcare practitioners.
1. The practitioner might consider discontinuing the practice of routinely prescribing
prophylactic antibiotics for patients with hip and knee prosthetic joint implants
undergoing dental procedures.
Grade of Recommendation: Limited
Definition: A Limited recommendation means the quality of the supporting evidence that exists is
unconvincing, or that well-conducted studies show little clear advantage to one approach versus
another.
Evidence from two or more “Low” strength studies with consistent findings, or evidence from a
single Moderate quality study recommending for or against the intervention or diagnostic.

Implications: Practitioners should be cautious in deciding whether to follow a recommendation
classified as Limited, and should exercise judgment and be alert to emerging publications that
report evidence. Patient preference should have a substantial influencing role.

2. We are unable to recommend for or against the use of topical oral antimicrobials
in patients with prosthetic joint implants or other orthopaedic implants undergoing
dental procedures.
Grade of Recommendation: Inconclusive
Definition: An Inconclusive recommendation means that there is a lack of compelling
evidence resulting in an unclear balance between benefits and potential harm.
Evidence from a single low quality study or conflicting findings that do not allow a
recommendation for or against the intervention.

Implications: Practitioners should feel little constraint in deciding whether to follow a
recommendation labeled as Inconclusive and should exercise judgment and be alert to future
publications that clarify existing evidence for determining balance of benefits versus potential
harm. Patient preference should have a substantial influencing role.

AAOS Clinical Practice Guideline Unit 3 v0.2 2.2.2012
3. In the absence of reliable evidence linking poor oral health to prosthetic joint
infection, it is the opinion of the work group that patients with prosthetic joint
implants or other orthopaedic implants maintain appropriate oral hygiene.
Grade of Recommendation: Consensus
Definition: A Consensus recommendation means that expert opinion supports the guideline
recommendation even though there is no available empirical evidence that meets the inclusion
criteria.
The supporting evidence is lacking and requires the work group to make a recommendation based
on expert opinion by considering the known potential harm and benefits associated with the
treatment.

Implications: Practitioners should be flexible in deciding whether to follow a recommendation
classified as Consensus, although they may set boundaries on alternatives. Patient preference
should have a substantial influencing role.

AAOS Clinical Practice Guideline Unit 4 v0.2 2.2.2012
Terminology Used in This Guideline
Direct evidence – Evidence that demonstrates a relationship between a dental procedure
and orthopaedic implant infection.
Indirect evidence – Evidence that demonstrates a relationship between a dental
procedure and a surrogate outcome (i.e. bacteremia).
Incidence – New cases of a disease that occur in an at-risk population during a specified
time period (i.e. a new bacteremia after a dental procedure)
Prevalence – Existing cases of a disease in a population during a specified time period
(i.e. a bacteremia that exists prior to a dental procedure)
Case-control study – Comparison of a diseased group (cases) to a group without disease
(controls)
Surrogate Outcome – An outcome (such as a laboratory measurement) that is used as a
substitute for a clinically relevant patient centered outcome
High, Moderate, and Low Strength Studies – Derived from quality and applicability
analysis; integrating multiple domains composed of questions related to study design and
methods (See Appraising Evidence Quality and Applicability)
AAOS Clinical Practice Guideline Unit 5 v0.2 2.2.2012
Prevention of Orthopaedic Implant Infection in Patients
Undergoing Dental Procedures
Clinical Practice Guideline Work Group

American Academy of Orthopaedic Surgeons American Dental Association
William Watters, III, MD, Co-Chair Elliot Abt, DDS
Bone and Joint Clinic of Houston 4709 Golf Road, Suite 1005
6624 Fannin Street, #2600 Skokie, IL 60076
Houston, TX 77030
American Dental Association
American Dental Association Harry C. Futrell, DMD
Michael P. Rethman, DDS, MS, Co-Chair 330 W 23rd Street, Suite J
47-140 Heno Place Panama City, FL 32405
Kaneohe, HI 96744
American Dental Association
American Academy of Orthopaedic Surgeons Stephen O. Glenn, DDS
Richard Parker Evans, MD 5319 S Lewis Avenue, Suite 222
Professor and Margaret Sue Neal Tulsa, OK 74105-6543
Endowed Chair of Orthopaedic Surgery
University of Missouri- Kansas City American Dental Association
School of Medicine John Hellstein, DDS, MS
2301 Holmes Street The University of Iowa, College of Dentistry
Kansas City, MO 64108 Department of Oral Pathology, Radiology and
Medicine
American Academy of Orthopaedic Surgeons DSB S356
Calin Moucha, MD Iowa City, IA 52242
Associate Chief, Joint Replacement Surgery
Mount Sinai Medical Center American Association of Hip and Knee Surgeons
Assistant Professor David Kolessar, MD
Leni & Peter W. May Department of Orthopaedic Geisinger Wyoming Valley Medical Center
Surgery 1000 East Mountain Boulevard
Mount Sinai School of Medicine Valley Medical Building
5 E. 98th Street, Box 1188, 7th Floor Wilkes-Barre, PA 18711
New York, NY 10029
American Association of Neurological
American Academy of Orthopaedic Surgeons Surgeons/Congress of Neurological Surgeons
Richard J. O'Donnell, MD John E. O'Toole, MD
Chief, UCSF Orthopaedic Oncology Service Assistant Professor of Neurosurgery
UCSF Sarcoma Program Rush University Medical Center
UCSF Helen Diller Family Comprehensive Cancer 1725 W. Harrison Street, Suite 970
Center Chicago, IL 60612
1600 Divisadero Street, 4th Floor
San Francisco, CA 94115 American Association of Oral and Maxillofacial
Surgeons
American Academy of Orthopaedic Surgeons & Mark J. Steinberg DDS, MD
Congress of Neurological Surgeons 1240 Meadow Road, Suite 300
Paul A. Anderson, MD Northbrook, IL 60062
Professor Department of Orthopedics &
Rehabilitation
University of Wisconsin
K4/735 600 Highland Avenue
Madison WI 53792

AAOS Clinical Practice Guideline Unit vi v0.2 2.2.2012
College of American Pathologist
Karen C. Carroll MD, FCAP AAOS Staff
Johns Hopkins Hospital Deborah S. Cummins, PhD
Department of Pathology-Microbiology Division Director, Research and Scientific Affairs
600 N Wolfe Street 6300 N. River Road
Meyer B1-193 Rosemont, IL 60018
Baltimore, MD 21287
Sharon Song, PhD
Knee Society Manager, Clinical Practice Guidelines
Kevin Garvin, MD [email protected]
University of Nebraska Medical Center
Creighton/Nebraska Health Fund Patrick Sluka, MPH
Department of Orthopaedic Surgery Former AAOS Lead Research Analyst
981080 Nebraska Medical Center
Omaha, Nebraska 68198-1080 Kevin Boyer
Former Appropriate Use Criteria Unit Manager
Musculoskeletal Infection Society Former Interim Clinical Practice Guidelines Manager
Douglas R. Osmon, MD
200 1st Street SW Anne Woznica, MLIS
Rochester, MN 55905 Medical Research Librarian

Scoliosis Research Society ADA Staff
Anthony Rinella, MD Helen Ristic, PhD.
Illinois Spine & Scoliosis Center Director, Scientific Information
12701 West 143rd Street, Suite 110 ADA Division of Science
Homer Glen, Illinois 60491 211 E. Chicago Avenue
Chicago, IL 60611
Society for Healthcare Epidemiology of America
Angela Hewlett, MD, MS Nicholas Buck Hanson, MPH
Assistant Professor, Section of Infectious Diseases ADA Lead Research Analyst
University of Nebraska Medical Center [email protected]
985400 Nebraska Medical Center
Omaha, Nebraska 68198 Special Recognitions
William Robert Martin, III, MD
Guidelines Oversight Chair American Academy of Orthopaedic Surgeons
Michael J. Goldberg, MD Medical Director
Children’s Hospital and Regional Medical Center 317 Massachusetts Avenue NE
1221 1st Avenue, Apt #24E Washington, D.C. 20002-5769
Seattle, WA 98101

Additional collaborating organizations involved in this guideline development:
Infectious Disease Society of America (IDSA)

AAOS Clinical Practice Guideline Unit vii v0.2 2.2.2012
Peer Review Organizations
Participation in the AAOS peer review process does not constitute an endorsement of this
guideline by the participating organization.

The following organizations participated in peer review of this clinical practice guideline and
gave explicit consent to be listed as peer reviewers:

The Academy of General Dentistry
American Academy of Oral Pathology
American Academy of Orthopaedic Surgeon’s Evidence Based Practice Committee
American Academy of Orthopaedic Surgeons’ Guidelines Oversight Committee
American Academy of Pediatric Dentistry
American Academy of Periodontology
American Association of Family Physicians
American Association of Hip and Knee Surgeons
American Association of Oral and Maxillofacial Surgeons
American Association of Public Health Dentistry
American College of Prosthodontists
American Dental Association’s Council on Scientific Affairs
American Dental Hygienists Association
Canadian Dental Association
Centers for Disease Control and Prevention
College of American Pathologists
Lumbar Spine Research Society
North American Spine Society
Society of Infectious Diseases Pharmacists
The Infectious Diseases Society of America

Participation in the AAOS peer review process does not constitute an endorsement of this
guideline by the participating organization.

AAOS Clinical Practice Guideline Unit viii v0.2 2.2.2012
Table of Contents
Summary of Recommendations ................................................................................................... 3
Terminology Used in This Guideline........................................................................................... 5
Work Group ................................................................................................................................. vi
Peer Review Organizations ....................................................................................................... viii
Table of Contents ......................................................................................................................... ix
List of Tables ............................................................................................................................... xii
List of Figures ............................................................................................................................. xiv
Introduction ................................................................................................................................... 1
Overview ..................................................................................................................................... 1
Goals and Rationale .................................................................................................................... 1
Intended Users ............................................................................................................................ 1
Patient Population ....................................................................................................................... 2
Burden of Disease and Etiology ................................................................................................. 2
Potential Harms, Benefits, and Contraindications ...................................................................... 2
Preventing Bias in an AAOS Clinical Practice Guideline ......................................................... 3
Methods .......................................................................................................................................... 9
Formulating Preliminary Recommendations .............................................................................. 9
Full Disclosure Information ........................................................................................................ 9
Study Selection Criteria .............................................................................................................. 9
Literature Searches.................................................................................................................... 10
Best Evidence Synthesis ........................................................................................................... 10
Appraising Evidence Quality and Applicability ....................................................................... 11
Studies of Interventions ........................................................................................................ 11
Studies of Incidence and Prevalence..................................................................................... 13
Studies of Prognostics ........................................................................................................... 14
Other Biases In the Published Literature .................................................................................. 15
Grades of Recommendation ...................................................................................................... 16
Wording of the Final Recommendations .................................................................................. 18
Consensus Recommendations ................................................................................................... 19
Voting on the Recommendations .............................................................................................. 20
Outcomes Considered ............................................................................................................... 20
Statistical Methods .................................................................................................................... 21
Peer Review .............................................................................................................................. 22
Public Commentary .................................................................................................................. 23
The AAOS Guideline Approval Process .................................................................................. 23
Revision Plans ........................................................................................................................... 24
Guideline Dissemination Plans ................................................................................................. 24
Overview of the Evidence ........................................................................................................... 25
Direct Evidence ......................................................................................................................... 25
Findings................................................................................................................................. 25
Quality and Applicability ...................................................................................................... 26
Results ................................................................................................................................... 26
Indirect Evidence: Dental Procedures and Bacteremia ............................................................. 28
Findings................................................................................................................................. 28
Quality and Applicability ...................................................................................................... 28
AAOS Clinical Practice Guideline Unit ix v0.2 2.2.2012
Results ................................................................................................................................... 29
Indirect Evidence: Risk Factors for Dental Procedure Related Bacteremia ............................. 33
Findings................................................................................................................................. 33
Quality and Applicability ...................................................................................................... 33
Results ................................................................................................................................... 34
Indirect Evidence: Prophylaxis for Dental Procedure Related Bacteremia .............................. 47
Findings................................................................................................................................. 47
Quality and Applicability ...................................................................................................... 47
Results ................................................................................................................................... 48
Indirect Evidence: Background Microbiology .......................................................................... 55
Findings................................................................................................................................. 55
Results ................................................................................................................................... 56
Recommendations ....................................................................................................................... 74
Recommendation 1 ................................................................................................................... 75
Rationale ............................................................................................................................... 75
Findings................................................................................................................................. 76
Quality and Applicability ...................................................................................................... 76
Results ................................................................................................................................... 76
Recommendation 2 ................................................................................................................... 85
Rationale ............................................................................................................................... 85
Findings................................................................................................................................. 85
Quality and Applicability ...................................................................................................... 85
Results ................................................................................................................................... 85
Recommendation 3 ................................................................................................................... 95
Rationale ............................................................................................................................... 95
Findings................................................................................................................................. 95
Quality and Applicability ...................................................................................................... 95
Future Research ...................................................................................................................... 105
Appendices ................................................................................................................................. 106
Appendix I .............................................................................................................................. 107
Work Group ........................................................................................................................ 107
Appendix II ............................................................................................................................. 109
Creating Preliminary Recommendations ............................................................................ 109
Appendix III ............................................................................................................................ 130
Study Attrition Diagram ..................................................................................................... 130
Included Studies Tables ...................................................................................................... 131
Excluded Studies Tables ..................................................................................................... 158
Appendix IV............................................................................................................................ 225
Medical Librarian Search Strategy ..................................................................................... 225
Supplemental Search ........................................................................................................... 228
Appendix V ............................................................................................................................. 231
Evaluating Quality and Applicability ................................................................................. 231
Studies of Interventions ...................................................................................................... 231
Studies of Incidence and Prevalence................................................................................... 234
Studies of Prognostics ......................................................................................................... 237
Appendix VI............................................................................................................................ 239
AAOS Clinical Practice Guideline Unit x v0.2 2.2.2012