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• W2144647564 abstract "We, as dentists, are confronted every day with decisions, and I am fascinated by how we make proper decisions and by what shapes these decisions. An area of particular interest is how we make treatment decisions and the evidence we use for making those decisions. The overarching question in my mind is: Are we making appropriate decisions regarding the use of antibiotics? Let's look at a few example, and ask questions about how our decisions are being made.For a nonlife-threatening acute dental infection in a patient with normal immune and metabolic status, an antibiotic (i.e., penicillin) is typically prescribed for a course of 7-10 days. However, what is so magical about this time frame? The usual oral infection of bacterial origin requires an average of 4-7 days to resolve with antibiotics.1Matijevic S. Lazic Z. Kuljic-Kapulica N. Nonkovic Z. Empirical antimicrobial therapy of acute dentoalveolar abscess.Vojnosanit Pregl. 2009; 66: 544-550Google Scholar, 2Mongtomery E.H. Yagiela J.A. Neidle E.A. Dowd F.J. Pharmacology and therapeutics for dentistry. Mosby, St. Louis1998: 482-495Google Scholar This raises the question, “Could our patients take an antibiotic for fewer days and still benefit from the antibiotic regimen?” Clearly, studies have shown that many individuals are not totally compliant with the prescribed antibiotic regimen and often have pills left over to take at a later date.3Feder Jr, H.M. Gerber M.A. Randolph M.F. Stelmach P.S. Kaplan E.L. Once-daily therapy for streptococcal pharyngitis with amoxicillin.Pediatrics. 1999; 103: 47-51Google Scholar, 4Clegg H.W. Ryan A.G. Dallas S.D. et al.Treatment of streptococcal pharyngitis with once-daily compared with twice-daily amoxicillin: a noninferiority trial.Pediatr Infect Dis J. 2006; 25: 761-767Google Scholar, 5Lennon D.R. Farrell E. Martin D.R. Stewart J.M. Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis.Arch Dis Child. 2008; 93: 474-478Google Scholar Furthermore, the indication that many patients survive the infection so that they could take the pills at a later date or share them with a relative or loved one suggests that the full course of antibiotic therapy was not required originally.It is also generally accepted that an antibiotic must reach the site of infection in amounts above the minimum inhibitory concentration (MIC) or minimum lethal concentration (MLC) for the infecting microorganisms. However, what about the immune response of a healthy individual? Could a concentration that is near the MLC be bacteriostatic and shift the balance enough so that the infection is controlled, particularly in an otherwise healthy patient? Alternatively, could the plasma concentration of the antibiotic be above the MIC for a minimum duration (e.g., just long enough, perhaps a few days) such that the immune system is capable of controlling the infection without taking a 7-day course of antibiotics?In dentistry we have the luxury often not afforded in medicine that we can reduce the bacterial load or remove the source of infection which can limit the need for antibiotics. For odontogenic infections, we can remove/reduce the source of infection by several means, including extraction, incision and drainage, or root canal therapy. In these circumstances, antibiotics can be discontinued after 2-3 days or may not even be needed provided that proper drainage has been established.6Ellison S.J. The role of phenoxymethylpenicillin, amoxicillin, metronidazole and clindamycin in the management of acute dentoalveolar abscesses—a review.Br Dent J. 2009; 206: 357-362Google Scholar, 7Pallasch T.J. How to use antibiotics effectively.J Calif Dent Assoc. 1993; 21: 46-50Google Scholar, 8Pogrel M.A. Antibiotics in general practice.Dent Update. 1994; 21: 274-280Google Scholar The need for many antibiotic prescriptions in dentistry is generally lacking, with one study reporting that only ∼5% of patients who received a prescription for antibiotics had an acute infection.9Lewis M.A. Meechan C. MacFarlane T.W. Lamey P.J. Kay E. Presentation and antimicrobial treatment of acute orofacial infections in general dental practice.Br Dent J. 1989; 166: 41-45Google Scholar Yet, many dentists write prescriptions for penicillins and do so using empirical 7-10 day dosing. This empirical approach could be optimized by studies that provide scientific evidence and by asking important questions before deciding to prescribe an antibiotic, questions such as: Is an antibiotic needed? Are the signs and symptoms consistent with an infection? Does the patient's health or current situation place them at risk for the infection spreading? If an antibiotic is needed, what duration of therapy is appropriate? By reevaluating the patient at 24, 48, and 72 hours after initial presentation for alleviation of signs and symptoms, the clinician could assess whether the proper drug was selected, whether the dose is effective/ineffective, and whether more days are needed. This approach could reduce exposure to the antibiotic.Now, some may say that giving a shorter course of high-dose antibiotics could lead to antibiotic resistance. But how does antibiotic resistance develop? Evidence indicates that long-term and repetitive use of antibiotics is what promotes antibiotic resistance.10Naiman R.A. Barrow J.G. Pencillin-resistant bacteria in the mouths and throats of children receiving continuous prophylaxis against rheumatic fever.Ann Intern Med. 1963; 58: 768-772Google Scholar, 11Sprunt K. Redman W. Leidy G. Penicillin resistant alpha streptococci in pharynx of patients given oral penicillin.Pediatrics. 1968; 42: 957-968Google Scholar Also, an adequate concentration needs to be maintained for a long enough period of time to promote selectivity for the development of resistant strains.12Bilavsky E. Eliahou R. Keller N. Yarden-Bilavsky H. Harel L. Amir J. Effect of benzathine penicillin treatment on antibiotic susceptibility of viridans streptococci in oral flora of patients receiving secondary prophylaxis after rheumatic fever.J Infect. 2008; 56: 244-248Google Scholar Furthermore, several lines of evidence support the concept that a short-course high-dose antibiotic regimen can be effective and should be considered for discontinuation after 3 days when proper drainage has been established and/or signs of the infection are resolving.7Pallasch T.J. How to use antibiotics effectively.J Calif Dent Assoc. 1993; 21: 46-50Google Scholar, 8Pogrel M.A. Antibiotics in general practice.Dent Update. 1994; 21: 274-280Google Scholar, 13Paterson S.A. Curzon M.E. The effect of amoxycillin versus penicillin V in the treatment of acutely abscessed primary teeth.Br Dent J. 1993; 174: 443-449Google Scholar, 14Marsh P. Martin M.V. Oral mcirobiology. Wright, Edinburgh1999Google Scholar, 15Martin M.V. Longman L.P. Hill J.B. Hardy P. Acute dentoalveolar infections: an investigation of the duration of antibiotic therapy.Br Dent J. 1997; 183: 135-137Google ScholarSo, let's take this intellectual debate a step further. Recently, the need for antibiotic prophylaxis for dental procedures for patients with joint prosthesis has reappeared in the news. In February 2009, the American Academy and American Association of Orthopedic Surgeons (AAOS) recommended that clinicians “consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive [dental] procedure that may cause bacteremia” [http://www.aaos.org/research/committee/ptsafety/ptsafety.asp (accessed Feb. 11, 2010)].Several things are interesting about this new recommendation. First, it more expansive than the American Dental Association (ADA) and AAOS advisory statement on the dental management of patients with prosthetic joints published in 1997 and revised in 2003.16American Dental Association, American Academy of Orthopaedic SurgeonsAdvisory statement Antibiotic prophylaxis for dental patients with total joint replacements.J Am Dent Assoc. 1997; 128: 1004-1008Google Scholar, 17Antibiotic prophylaxis for dental patients with total joint replacements.J Am Dent Assoc. 2003; 134: 895-899Google Scholar This new recommendation includes “any invasive procedure that may cause bacteremia.” The main premise for this recommendation is that: 1) bacteremia from oral flora arising from dental procedures causes late prosthetic joint infections (LPJIs); 2) there is a temporal relationship between dental procedures and LPJIs; 3) antibiotic prophylaxis would prevent bacterial seeding and subsequent LPJIs; and 4) treatment of LPJIs is expensive, involving hospitalization, pain, immobility, and possible implant removal.In a recent commentary, Dr. Arthur Friedlander supported the AAOS recommendation by presenting a case for the presence of staphylococci in the oral cavity, especially in the elderly and those with rheumatoid arthritis, as well as around implants, root canals, and odontogenic infections.18Percival R.S. Challacombe S.J. Marsh P.D. Age-related microbiological changes in the salivary and plaque microflora of healthy adults.J Med Microbiol. 1991; 35: 5-11Google Scholar, 19Marsh P.D. Percival R.S. Challacombe S.J. The influence of denture-wearing and age on the oral microflora.J Dent Res. 1992; 71: 1374-1381Google Scholar, 20Honda E. Oral microbial flora and oral malodour of the institutionalised elderly in Japan.Gerodontology. 2001; 18: 65-72Google Scholar, 21Baena-Monroy T. Moreno-Maldonado V. Franco-Martinez F. Aldape-Barrios B. Quindos G. Sanchez-Vargas L.O. Candida albicans, Staphylococcus aureus and Streptococcus mutans colonization in patients wearing dental prosthesis.Med Oral Patol Oral Cir Bucal. 2005; 10: E27-E39Google Scholar, 22Jacobson J.J. Patel B. Asher G. Woolliscroft J.O. Schaberg D. Oral staphylococcus in older subjects with rheumatoid arthritis.J Am Geriatr Soc. 1997; 45: 590-593Google Scholar, 23Murdoch F.E. Sammons R.L. Chapple I.L. Isolation and characterization of subgingival staphylococci from periodontitis patients and controls.Oral Dis. 2004; 10: 155-162Google Scholar, 24Fischer C.C. Persson R.E. Persson G.R. Influence of the menstrual cycle on the oral microbial flora in women: a case-control study including men as control subjects.J Periodontol. 2008; 79: 1966-1973Google Scholar, 25Salvi G.E. Furst M.M. Lang N.P. Persson G.R. One-year bacterial colonization patterns of Staphylococcus aureus and other bacteria at implants and adjacent teeth.Clin Oral Implants Res. 2008; 19: 242-248Google Scholar, 26Egusa H. Watamoto T. Abe K. et al.An analysis of the persistent presence of opportunistic pathogens on patient-derived dental impressions and gypsum casts.Int J Prosthodont. 2008; 21: 62-68Google Scholar He reviews the rates of bacterial infections of prosthetic joints temporally and bacteriologically associated with dental procedures and reiterates the findings from 2 large studies by Laporte et al.27LaPorte D.M. Waldman B.J. Mont M.A. Hungerford D.S. Infections associated with dental procedures in total hip arthroplasty.J Bone Joint Surg Br. 1999; 81: 56-59Google Scholar and Waldman et al.,28Waldman B.J. Mont M.A. Hungerford D.S. Total knee arthroplasty infections associated with dental procedures.Clin Orthop Relat Res. 1997; : 164-172Google Scholar where 12 “dentally-related” joint infections were identified from more than 6,400 patients with prosthetic joints. His commentary states that “the oral microbial environment are more diverse than originally believed and … [thus], it logically follows that invasive dental procedures (oral and periodontal surgery, scaling, root planing, probing, dental implant placement, endodontic instrumentation beyond root apex, placement of subgingival fibers or strips, intraligamentary injections, and prophylactic cleaning of teeth or implants where bleeding is anticipated) may cause both staphylococcus and streptococcus bacteremias which have been implicated in late joint prostheses infections.” Dr. Friedlander then presents an antibiotic regimen supported by orthopedic societies that he and they recommend for use.Here is where our decision-making skills are put to the test. No one will disagree that bacteria in the oral cavity may be associated with bacteremias, and few will disagree that these organisms have a temporal relationship with a small number of LJPIs. However, closer scrutiny of the evidence is required. Bacteremias associated with daily activities are common, yet no one recommends (yet) the need for daily prophylactic antibiotics when these patients chew gum or brush their teeth.29Hupp J.R. Infective endocarditis—stop blaming the dentist.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 108: 145-146Google Scholar Second, no one has cultured the organisms in the mouth before and then during the LJPI, so therefore the relationship between the 2 sites is only predicted and not proven. Third, analyses of reported cases of LJPIs demonstrate that these infections are rarely caused by bacterial species common to the mouth.27LaPorte D.M. Waldman B.J. Mont M.A. Hungerford D.S. Infections associated with dental procedures in total hip arthroplasty.J Bone Joint Surg Br. 1999; 81: 56-59Google Scholar, 28Waldman B.J. Mont M.A. Hungerford D.S. Total knee arthroplasty infections associated with dental procedures.Clin Orthop Relat Res. 1997; : 164-172Google Scholar, 30Lindqvist C. Slatis P. Dental bacteremia—a neglected cause of arthroplasty infections? Three hip cases.Acta Orthop Scand. 1985; 56: 506-508Google Scholar Fourth, a recent well designed, case-control study performed at the Mayo Clinic in response to the AAOS posting demonstrated that dental procedures were not risk factors for subsequent total hip or knee infections.31Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. Clin Infect Dis;50:8-16.Google Scholar Finally, no study exists that has shown that prophylactic antibiotics reduce the risk of distant site infections in humans.32Wilson W. Taubert K.A. Gewitz M. et al.Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.Circulation. 2007; 116: 1736-1754Google Scholar, 33Lockhart P.B. Loven B. Brennan M.T. Fox P.C. The evidence base for the efficacy of antibiotic prophylaxis in dental practice.J Am Dent Assoc. 2007; 138: 458-474Google Scholar, 34Oliver R. Roberts G.J. Hooper L. Worthington H.V. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry.Cochrane Database Syst Rev. 2008; (CD003813)Google Scholar In fact, one of the 9 “dentally related” joint infections documented in the Waldman et al.28Waldman B.J. Mont M.A. Hungerford D.S. Total knee arthroplasty infections associated with dental procedures.Clin Orthop Relat Res. 1997; : 164-172Google Scholar report received prophylactic antibiotics, but the antibiotics failed to be protective. So, one could extrapolate from these data that the risk of LJPI is small with or without dental treatment, and antibiotic prophylaxis is at best 89% efficient in preventing LJPIs.Let's consider additional factors that could help in the decision process. Pertinent questions include: First, what is the bacterial load in the oral cavity at the time of the procedure, and how does the load relate to risk of prosthetic joint infections? Second, which procedures involve significant risk of bacteremia (e.g., incision into infected tissues vs. placement of subgingival fibers or strips)? Third, how does the duration of the procedure influence the outcome? In the original reports provided by LaPorte et al. and Waldman et al., the duration of the invasive dental procedures associated with the infections were 45-90 minutes and 75-205 minutes, respectively. One could speculate that the duration of the invasive procedure being ≥45 minutes was an important risk factor, because in theory bacteria could have had an increased opportunity to enter the blood stream if the invasion was longer. Also potentially contributory is the patient's immune and metabolic status. In the LaPorte et al. and Waldman et al. reports, ∼50% of the patients who developed LJPIs were immune- or metabolically compromised, and these systemic alterations have been identified as potentially higher risk since the 1997 ADA/AAOS advisory statement.In conclusion, much data and controversy exist regarding the proper use of antibiotics for infections and prophylactically. However, clinicians are encouraged to weigh the evidence from weakest (empirical approaches and expert opinions) to strongest (carefully controlled clinical trials) for guiding their clinical judgment. After all, that is how practice guidelines should be established. Rest assured that in the future, these guidelines will be strengthened based on studies that address the effects of antibiotics at the site of interest, adverse effects associated with antibiotic use, development of antibiotic resistance, cost implications (prophylaxis vs. joint replacement surgery), and quality of life issues. We, as dentists, are confronted every day with decisions, and I am fascinated by how we make proper decisions and by what shapes these decisions. An area of particular interest is how we make treatment decisions and the evidence we use for making those decisions. The overarching question in my mind is: Are we making appropriate decisions regarding the use of antibiotics? Let's look at a few example, and ask questions about how our decisions are being made. For a nonlife-threatening acute dental infection in a patient with normal immune and metabolic status, an antibiotic (i.e., penicillin) is typically prescribed for a course of 7-10 days. However, what is so magical about this time frame? The usual oral infection of bacterial origin requires an average of 4-7 days to resolve with antibiotics.1Matijevic S. Lazic Z. Kuljic-Kapulica N. Nonkovic Z. Empirical antimicrobial therapy of acute dentoalveolar abscess.Vojnosanit Pregl. 2009; 66: 544-550Google Scholar, 2Mongtomery E.H. Yagiela J.A. Neidle E.A. Dowd F.J. Pharmacology and therapeutics for dentistry. Mosby, St. Louis1998: 482-495Google Scholar This raises the question, “Could our patients take an antibiotic for fewer days and still benefit from the antibiotic regimen?” Clearly, studies have shown that many individuals are not totally compliant with the prescribed antibiotic regimen and often have pills left over to take at a later date.3Feder Jr, H.M. Gerber M.A. Randolph M.F. Stelmach P.S. Kaplan E.L. Once-daily therapy for streptococcal pharyngitis with amoxicillin.Pediatrics. 1999; 103: 47-51Google Scholar, 4Clegg H.W. Ryan A.G. Dallas S.D. et al.Treatment of streptococcal pharyngitis with once-daily compared with twice-daily amoxicillin: a noninferiority trial.Pediatr Infect Dis J. 2006; 25: 761-767Google Scholar, 5Lennon D.R. Farrell E. Martin D.R. Stewart J.M. Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis.Arch Dis Child. 2008; 93: 474-478Google Scholar Furthermore, the indication that many patients survive the infection so that they could take the pills at a later date or share them with a relative or loved one suggests that the full course of antibiotic therapy was not required originally. It is also generally accepted that an antibiotic must reach the site of infection in amounts above the minimum inhibitory concentration (MIC) or minimum lethal concentration (MLC) for the infecting microorganisms. However, what about the immune response of a healthy individual? Could a concentration that is near the MLC be bacteriostatic and shift the balance enough so that the infection is controlled, particularly in an otherwise healthy patient? Alternatively, could the plasma concentration of the antibiotic be above the MIC for a minimum duration (e.g., just long enough, perhaps a few days) such that the immune system is capable of controlling the infection without taking a 7-day course of antibiotics? In dentistry we have the luxury often not afforded in medicine that we can reduce the bacterial load or remove the source of infection which can limit the need for antibiotics. For odontogenic infections, we can remove/reduce the source of infection by several means, including extraction, incision and drainage, or root canal therapy. In these circumstances, antibiotics can be discontinued after 2-3 days or may not even be needed provided that proper drainage has been established.6Ellison S.J. The role of phenoxymethylpenicillin, amoxicillin, metronidazole and clindamycin in the management of acute dentoalveolar abscesses—a review.Br Dent J. 2009; 206: 357-362Google Scholar, 7Pallasch T.J. How to use antibiotics effectively.J Calif Dent Assoc. 1993; 21: 46-50Google Scholar, 8Pogrel M.A. Antibiotics in general practice.Dent Update. 1994; 21: 274-280Google Scholar The need for many antibiotic prescriptions in dentistry is generally lacking, with one study reporting that only ∼5% of patients who received a prescription for antibiotics had an acute infection.9Lewis M.A. Meechan C. MacFarlane T.W. Lamey P.J. Kay E. Presentation and antimicrobial treatment of acute orofacial infections in general dental practice.Br Dent J. 1989; 166: 41-45Google Scholar Yet, many dentists write prescriptions for penicillins and do so using empirical 7-10 day dosing. This empirical approach could be optimized by studies that provide scientific evidence and by asking important questions before deciding to prescribe an antibiotic, questions such as: Is an antibiotic needed? Are the signs and symptoms consistent with an infection? Does the patient's health or current situation place them at risk for the infection spreading? If an antibiotic is needed, what duration of therapy is appropriate? By reevaluating the patient at 24, 48, and 72 hours after initial presentation for alleviation of signs and symptoms, the clinician could assess whether the proper drug was selected, whether the dose is effective/ineffective, and whether more days are needed. This approach could reduce exposure to the antibiotic. Now, some may say that giving a shorter course of high-dose antibiotics could lead to antibiotic resistance. But how does antibiotic resistance develop? Evidence indicates that long-term and repetitive use of antibiotics is what promotes antibiotic resistance.10Naiman R.A. Barrow J.G. Pencillin-resistant bacteria in the mouths and throats of children receiving continuous prophylaxis against rheumatic fever.Ann Intern Med. 1963; 58: 768-772Google Scholar, 11Sprunt K. Redman W. Leidy G. Penicillin resistant alpha streptococci in pharynx of patients given oral penicillin.Pediatrics. 1968; 42: 957-968Google Scholar Also, an adequate concentration needs to be maintained for a long enough period of time to promote selectivity for the development of resistant strains.12Bilavsky E. Eliahou R. Keller N. Yarden-Bilavsky H. Harel L. Amir J. Effect of benzathine penicillin treatment on antibiotic susceptibility of viridans streptococci in oral flora of patients receiving secondary prophylaxis after rheumatic fever.J Infect. 2008; 56: 244-248Google Scholar Furthermore, several lines of evidence support the concept that a short-course high-dose antibiotic regimen can be effective and should be considered for discontinuation after 3 days when proper drainage has been established and/or signs of the infection are resolving.7Pallasch T.J. How to use antibiotics effectively.J Calif Dent Assoc. 1993; 21: 46-50Google Scholar, 8Pogrel M.A. Antibiotics in general practice.Dent Update. 1994; 21: 274-280Google Scholar, 13Paterson S.A. Curzon M.E. The effect of amoxycillin versus penicillin V in the treatment of acutely abscessed primary teeth.Br Dent J. 1993; 174: 443-449Google Scholar, 14Marsh P. Martin M.V. Oral mcirobiology. Wright, Edinburgh1999Google Scholar, 15Martin M.V. Longman L.P. Hill J.B. Hardy P. Acute dentoalveolar infections: an investigation of the duration of antibiotic therapy.Br Dent J. 1997; 183: 135-137Google Scholar So, let's take this intellectual debate a step further. Recently, the need for antibiotic prophylaxis for dental procedures for patients with joint prosthesis has reappeared in the news. In February 2009, the American Academy and American Association of Orthopedic Surgeons (AAOS) recommended that clinicians “consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive [dental] procedure that may cause bacteremia” [http://www.aaos.org/research/committee/ptsafety/ptsafety.asp (accessed Feb. 11, 2010)]. Several things are interesting about this new recommendation. First, it more expansive than the American Dental Association (ADA) and AAOS advisory statement on the dental management of patients with prosthetic joints published in 1997 and revised in 2003.16American Dental Association, American Academy of Orthopaedic SurgeonsAdvisory statement Antibiotic prophylaxis for dental patients with total joint replacements.J Am Dent Assoc. 1997; 128: 1004-1008Google Scholar, 17Antibiotic prophylaxis for dental patients with total joint replacements.J Am Dent Assoc. 2003; 134: 895-899Google Scholar This new recommendation includes “any invasive procedure that may cause bacteremia.” The main premise for this recommendation is that: 1) bacteremia from oral flora arising from dental procedures causes late prosthetic joint infections (LPJIs); 2) there is a temporal relationship between dental procedures and LPJIs; 3) antibiotic prophylaxis would prevent bacterial seeding and subsequent LPJIs; and 4) treatment of LPJIs is expensive, involving hospitalization, pain, immobility, and possible implant removal. In a recent commentary, Dr. Arthur Friedlander supported the AAOS recommendation by presenting a case for the presence of staphylococci in the oral cavity, especially in the elderly and those with rheumatoid arthritis, as well as around implants, root canals, and odontogenic infections.18Percival R.S. Challacombe S.J. Marsh P.D. Age-related microbiological changes in the salivary and plaque microflora of healthy adults.J Med Microbiol. 1991; 35: 5-11Google Scholar, 19Marsh P.D. Percival R.S. Challacombe S.J. The influence of denture-wearing and age on the oral microflora.J Dent Res. 1992; 71: 1374-1381Google Scholar, 20Honda E. Oral microbial flora and oral malodour of the institutionalised elderly in Japan.Gerodontology. 2001; 18: 65-72Google Scholar, 21Baena-Monroy T. Moreno-Maldonado V. Franco-Martinez F. Aldape-Barrios B. Quindos G. Sanchez-Vargas L.O. Candida albicans, Staphylococcus aureus and Streptococcus mutans colonization in patients wearing dental prosthesis.Med Oral Patol Oral Cir Bucal. 2005; 10: E27-E39Google Scholar, 22Jacobson J.J. Patel B. Asher G. Woolliscroft J.O. Schaberg D. Oral staphylococcus in older subjects with rheumatoid arthritis.J Am Geriatr Soc. 1997; 45: 590-593Google Scholar, 23Murdoch F.E. Sammons R.L. Chapple I.L. Isolation and characterization of subgingival staphylococci from periodontitis patients and controls.Oral Dis. 2004; 10: 155-162Google Scholar, 24Fischer C.C. Persson R.E. Persson G.R. Influence of the menstrual cycle on the oral microbial flora in women: a case-control study including men as control subjects.J Periodontol. 2008; 79: 1966-1973Google Scholar, 25Salvi G.E. Furst M.M. Lang N.P. Persson G.R. One-year bacterial colonization patterns of Staphylococcus aureus and other bacteria at implants and adjacent teeth.Clin Oral Implants Res. 2008; 19: 242-248Google Scholar, 26Egusa H. Watamoto T. Abe K. et al.An analysis of the persistent presence of opportunistic pathogens on patient-derived dental impressions and gypsum casts.Int J Prosthodont. 2008; 21: 62-68Google Scholar He reviews the rates of bacterial infections of prosthetic joints temporally and bacteriologically associated with dental procedures and reiterates the findings from 2 large studies by Laporte et al.27LaPorte D.M. Waldman B.J. Mont M.A. Hungerford D.S. Infections associated with dental procedures in total hip arthroplasty.J Bone Joint Surg Br. 1999; 81: 56-59Google Scholar and Waldman et al.,28Waldman B.J. Mont M.A. Hungerford D.S. Total knee arthroplasty infections associated with dental procedures.Clin Orthop Relat Res. 1997; : 164-172Google Scholar where 12 “dentally-related” joint infections were identified from more than 6,400 patients with prosthetic joints. His commentary states that “the oral microbial environment are more diverse than originally believed and … [thus], it logically follows that invasive dental procedures (oral and periodontal surgery, scaling, root planing, probing, dental implant placement, endodontic instrumentation beyond root apex, placement of subgingival fibers or strips, intraligamentary injections, and prophylactic cleaning of teeth or implants where bleeding is anticipated) may cause both staphylococcus and streptococcus bacteremias which have been implicated in late joint prostheses infections.” Dr. Friedlander then presents an antibiotic regimen supported by orthopedic societies that he and they recommend for use. Here is where our decision-making skills are put to the test. No one will disagree that bacteria in the oral cavity may be associated with bacteremias, and few will disagree that these organisms have a temporal relationship with a small number of LJPIs. However, closer scrutiny of the evidence is required. Bacteremias associated with daily activities are common, yet no one recommends (yet) the need for daily prophylactic antibiotics when these patients chew gum or brush their teeth.29Hupp J.R. Infective endocarditis—stop blaming the dentist.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 108: 145-146Google Scholar Second, no one has cultured the organisms in the mouth before and then during the LJPI, so therefore the relationship between the 2 sites is only predicted and not proven. Third, analyses of reported cases of LJPIs demonstrate that these infections are rarely caused by bacterial species common to the mouth.27LaPorte D.M. Waldman B.J. Mont M.A. Hungerford D.S. Infections associated with dental procedures in total hip arthroplasty.J Bone Joint Surg Br. 1999; 81: 56-59Google Scholar, 28Waldman B.J. Mont M.A. Hungerford D.S. Total knee arthroplasty infections associated with dental procedures.Clin Orthop Relat Res. 1997; : 164-172Google Scholar, 30Lindqvist C. Slatis P. Dental bacteremia—a neglected cause of arthroplasty infections? Three hip cases.Acta Orthop Scand. 1985; 56: 506-508Google Scholar Fourth, a recent well designed, case-control study performed at the Mayo Clinic in response to the AAOS posting demonstrated that dental procedures were not risk factors for subsequent total hip or knee infections.31Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. Clin Infect Dis;50:8-16.Google Scholar Finally, no study exists that has shown that prophylactic antibiotics reduce the risk of distant site infections in humans.32Wilson W. Taubert K.A. Gewitz M. et al.Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.Circulation. 2007; 116: 1736-1754Google Scholar, 33Lockhart P.B. Loven B. Brennan M.T. Fox P.C. The evidence base for the efficacy of antibiotic prophylaxis in dental practice.J Am Dent Assoc. 2007; 138: 458-474Google Scholar, 34Oliver R. Roberts G.J. Hooper L. Worthington H.V. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry.Cochrane Database Syst Rev. 2008; (CD003813)Google Scholar In fact, one of the 9 “dentally related” joint infections documented in the Waldman et al.28Waldman B.J. Mont M.A. Hungerford D.S. Total knee arthroplasty infections associated with dental procedures.Clin Orthop Relat Res. 1997; : 164-172Google Scholar report received prophylactic antibiotics, but the antibiotics failed to be protective. So, one could extrapolate from these data that the risk of LJPI is small with or without dental treatment, and antibiotic prophylaxis is at best 89% efficient in preventing LJPIs. Let's consider additional factors that could help in the decision process. Pertinent questions include: First, what is the bacterial load in the oral cavity at the time of the procedure, and how does the load relate to risk of prosthetic joint infections? Second, which procedures involve significant risk of bacteremia (e.g., incision into infected tissues vs. placement of subgingival fibers or strips)? Third, how does the duration of the procedure influence the outcome? In the original reports provided by LaPorte et al. and Waldman et al., the duration of the invasive dental procedures associated with the infections were 45-90 minutes and 75-205 minutes, respectively. One could speculate that the duration of the invasive procedure being ≥45 minutes was an important risk factor, because in theory bacteria could have had an increased opportunity to enter the blood stream if the invasion was longer. Also potentially contributory is the patient's immune and metabolic status. In the LaPorte et al. and Waldman et al. reports, ∼50% of the patients who developed LJPIs were immune- or metabolically compromised, and these systemic alterations have been identified as potentially higher risk since the 1997 ADA/AAOS advisory statement. In conclusion, much data and controversy exist regarding the proper use of antibiotics for infections and prophylactically. However, clinicians are encouraged to weigh the evidence from weakest (empirical approaches and expert opinions) to strongest (carefully controlled clinical trials) for guiding their clinical judgment. After all, that is how practice guidelines should be established. Rest assured that in the future, these guidelines will be strengthened based on studies that address the effects of antibiotics at the site of interest, adverse effects associated with antibiotic use, development of antibiotic resistance, cost implications (prophylaxis vs. joint replacement surgery), and quality of life issues." @default.
• W2144647564 created "2016-06-24" @default.
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• W2144647564 date "2010-07-01" @default.
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