One Size Does Not Fit All

The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA), along with input from the Infectious Disease Society of America (IDSA), American Association of Oral and Maxillofacial Surgeons (AAOMS), American Association of Neurologic Surgeons (AANS), American Society of Plastic Surgeons (ASPS), Musculoskeletal Infection Society (MIS), Scoliosis Research Society (SRS), American Association of Hip and Knee Surgeons (AAHKS), Society for Healthcare Epidemiology of America (SHEA), College of American Pathologists, and The Knee Society, published the collaborative clinical practice guideline (CPG) “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures” on December 7, 2012.1 This AAOS-ADA guideline on dental prophylaxis for patients with orthopaedic implants addressed the weaknesses of previous efforts based on a systematic review of available evidence. The CPG also united the position of these organizations with respect to the necessity of dental prophylaxis in these patient groups, eliminating the contradictory guidelines and statements published by both the AAOS and ADA before 2012. Unfortunately, the halo effect of this unified position was limited, as evidenced by the recent ADA publication “The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints.”2 This new ADA guideline again creates disagreement between the ADA and AAOS, along with associated specialty societies, including the AAHKS, The Hip Society, and The Knee Society, because the ADA CPG makes a moderate recommendation against routine dental prophylaxis in patients who have undergone hip and/or knee arthroplasty. This recommendation is at odds with the previous recommendation in the 2012 collaborative CPG supported by limited evidence. Our primary concern with the work of the ADA is that it is not supported by evidence and should, in fact, be labeled a consensus statement. The ADA guideline incorrectly includes three lower quality research articles to develop a stronger recommendation, which is not actually supported by evidence. We also object to this 2014 ADA manuscript’s being referred to as an “updated” CPG because it uses different inclusion criteria from those of the 2012 AAOS-ADA CPG. For example, it includes articles (Swan et al,3 Jacobson et al4) that were specifically excluded by the multidisciplinary team that developed the 2012 CPG because these are retrospective studies that do not meet the criteria for inclusion. The third study added by the ADA (Skaar et al5) was published after the last literature search was done for the 2012 CPG, but it also would be excluded in a collaborative update because it is also a retrospective study. No additional higher quality evidence has been published since the 2012 AAOS-ADA CPG, so no change to the strength or level of recommendation is indicated. The 2012 AAOS-ADA CPG did not include a stronger recommendation because the current evidence base does not support it. Rather, concerns about the lack of subgroup analysis suggested a metered approach to recommending antibiotic prophylaxis for patients with hip or knee arthroplasty undergoing dental work. Clinician assessment of individual patient risk factors was recommended, as well as the use of a shared decision-making approach to determining appropriate care. The work group expressed concern about nuance of care in these patients, and this was supported by the paucity of higher quality evidence available. We are also compelled to express our concern about the unilateral approach taken by the ADA to this issue. Apparently, dentists who were unhappy with the outcome of the original 2012 CPG lobbied for a non-inclusive, non–evidence-based methodology rather than stand by the current best-available evidence. By publishing a consensus guideline that contradicts its previous evidence-based position, the ADA further muddies potential liability issues for their members as well as AAOS members. We believe that the patient care benefit of a collaborative position on the issue of dental prophylaxis is considerable and that the new ADA position may actually decrease care offered to our patients. It also exposes a potential for opposing positions in a litigation scenario. Finally, the purpose of collaboration is to improve care delivery to and education of our patients. The AAOS has a rich history of collaboration with several non-orthopaedic societies as well as affiliate provider groups. When involved in these collaborative efforts, we take at face value a level of trust in supporting the outcome of these interactions. Although the results of evidence-based efforts sometimes disagree with our routine patterns of care, adherence to evidence-based methodology and outcome should not be undermined by political expediency. The new ADA guideline2 appears to lessen the commitment by the ADA to evidence-based care of its members’ patients. Because of the lack of evidence for this topic, derivative products such as appropriate use criteria and shared decision-making resources that use clinical expertise to form treatment recommendations may be better tools. More and better studies are needed to provide clear evidence regarding the correlation between dental procedures and periprosthetic joint infection in patients with orthopaedic implants. Those who may want to criticize these guideline recommendations should take note that the available literature is the basis for these recommendations. Finally, the practice of evidence-based medicine is based on three pillars: the patient’s preferences and values, the clinician (and the clinician’s experience), and the evidence. Clinicians, both physicians and their dentist counterparts, should work with their individual patients and each other to customize care delivery based on the available evidence. It is hoped that this guideline will stimulate future research in this area.