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Evidence-based clinical practice guideline for dental practitioners—a report of the American Dental Association Council on Scientific Affairs

Thomas P. Sollecito, DMD, FDS RCSEd; Elliot Abt, DDS, MS, MSc; Peter B. Lockhart, DDS, FDS RCSEd, FDS RCPS; Edmond Truelove, DDS, MSD; Thomas M. Paumier, DDS; Sharon L. Tracy, PhD; Malavika Tampi, MPH; Eugenio D. Beltrán-Aguilar, DMD, MPH, MS, DrPH; Julie Frantsve-Hawley, PhD

In 2012, a panel of experts representing the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) (the 2012 Panel) published a systematic review and accompanying clinical practice guideline (CPG) entitled “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-based Guideline and Evidence Report.”1-3 The 2012 Panel initially considered 222 questions concerning the relationship between dental procedures, bacteremia (as an intermediate outcome), and the risk of developing a prosthetic joint infection (PJI) as a clinical end point. The 2012 Panel published a comprehensive evidence-based guideline. The release of this guideline was followed by calls to the ADA Member Service Center hotline requesting additional clarification, which indicated that this guideline was 1 of the top 2 issues of concern to dental practitioners. Therefore, the ADA’s Council on Scientific Affairs convened a panel of experts (the 2014 Panel) to provide dental professionals with a more specific and practical set of guidelines, the results of which are included in this article.

The 2014 Panel considered the direct evidence linking a PJI with a dental procedure but did not reevaluate intermediate outcomes, including bacteremia4 from manipulation of oral mucosa. The full report of the 2012 Panel, which includes intermediate outcomes, is available online.1 The 2014 Panel addressed the following clinical question: For patients with prosthetic joints, is there an association between dental procedures and PJI, and, therefore, should systemic antibiotics be prescribed before patients with prosthetic joint implants undergo dental procedures? In this article, we present the evidence to answer this question and provide clinical recommendations.

To read more about this article, please click here to download.

This article has an accompanying online continuing education activity available at: http://jada.ada.org/ce/home. Copyright 2015 American Dental Association. All rights reserved.

Article from MouthHealthy.org

Gum disease is not that common
On the contrary, gum disease is extremely common. According to the Centers for Disease Control and Prevention, half of adults age 30 and older suffer from some form of gum disease. Gum disease, an infection of the tissues that surround and support your teeth, is caused by plaque, the sticky film of bacteria that is constantly forming on our teeth. Plaque that is not removed with thorough daily brushing and cleaning between teeth can eventually harden into calculus or tartar.

I don’t have cavities so I can’t have gum disease
Being cavity-free doesn’t ensure you are in the clear where gum disease is concerned. That’s because gum disease is painless and many people have no idea they have it. Gums that bleed easily or are red, swollen or tender is a sign of gingivitis, the earliest stage of gum disease and the only stage that is reversible. When caught early gingivitis can usually be eliminated by a professional cleaning at the dental office, followed by daily brushing and flossing.

Having gum disease means I will lose my teeth
Not so! You don’t have to lose any of your teeth to gum disease if you practice good oral hygiene. That means brushing your teeth twice a day, cleaning between your teeth daily, eating a healthy diet, and scheduling regular dental visits. Even if you are diagnosed with gum disease, your dentist can design a treatment plan to help you keep it under control.

Bleeding gums during pregnancy is normal
While it’s true that some women develop a condition known as “pregnancy gingivitis,” it’s not true that everyone experiences this. You can help prevent this condition by taking extra care during your brushing and flossing routine. Your dentist may recommend more frequent cleanings to prevent this.

Bad breath can be an indicator of gum disease
Persistent bad breath or a bad taste in your mouth can be an indicator of gum disease and other oral diseases so it is important that you uncover what’s causing the problem. If constantly have bad breath, make an appointment to see your dentist. Regular checkups allow your dentist to detect any problems as your bad breath may be the sign of a medical disorder. If your dentist determines that your mouth is healthy, you may be referred to your primary care physician.

I have diabetes. Will I get gum disease
Diabetes is a chronic disease which affects your body’s ability to process sugar. The resulting high blood sugar can cause problems with your eyes, nerves, kidneys, heart and other parts of your body. Diabetes can also lower your resistance to infection and can slow the healing process. If you have diabetes, you are at greater risk of developing some oral health problems, including gum disease, so it’s important that you are extra diligent with your oral health.

For more information, please visit www.mouthhealthy.org

Recommendations regarding the use of antimicrobial prophylaxis to prevent bacterial endocarditis and prosthetic joint infections in selected patients undergoing dental procedures are presented separately.

SUMMARY AND RECOMMENDATIONS

• Odontogenic infections, consisting primarily of dental caries and periodontal disease (gingivitis and periodontitis), are common and have local (eg, tooth loss) and, in some cases, systemic implications. Suppurative odontogenic infections may extend to potential fascial spaces in the orofacial area (orofacial space infections) or deep in the head and neck (peripharyngeal space infections). The latter complication is often life threatening. Odontogenic infections can also result in osteomyelitis of the jaw or hematogenous dissemination, which may in turn cause endocarditis or prosthetic joint infections. (See ‘Introduction’ above and ‘Complications’ above.)
• For closed space infections, it is imperative that the normal oral flora be excluded during specimen collection in order to interpret culture results. Needle aspiration of loculated pus by an extraoral approach is desirable, and specimens should be transported immediately to the laboratory under anaerobic conditions. (See ‘Specimen collection and processing’ above.)
• The choice of imaging technique varies with the clinical setting. Computed tomography (CT) is particularly sensitive for osseous structures and remains the imaging modality of choice for assessment of most odontogenic infections. (See ‘Imaging techniques’ above.)
• Meticulous attention to oral hygiene is the most important strategy for effective control of supragingival and subgingival plaque that, in turn, is essential for both caries prevention and the treatment of periodontitis. (See ‘Therapeutic considerations’ above.)
• Pulpitis, inflammation of the dental pulp, occurs when progression of dental caries exposes the dental pulp, leading to infection (figure 3). The early and dominant symptom of acute pulpitis is a severe toothache that can be elicited by thermal changes, especially cold drinks. Apart from removal of the tooth, the customary approach to relieving the pain of irreversible pulpitis is by drilling into the tooth, removing the inflamed pulp (nerve), and cleaning the root canal. (See ‘Pulpitis’ above.)
• Acute simple gingivitis rarely requires systemic antimicrobial therapy. Chlorhexidine 0.12 percent oral rinse can be used in most cases. Exceptions include patients with rapidly advancing disease, severe pain, or HIV infection in whom systemic therapy is indicated. Possible regimens include penicillin plus metronidazole, amoxicillin-clavulanate, ampicillin-sulbactam, or clindamycin (table 2). (See ‘Acute gingivitis’ above.)
• Acute necrotizing ulcerative gingivitis, also known as Vincent’s angina or trench mouth, should be treated with systemic antimicrobials, such as metronidazole, amoxicillin-clavulanate, ampicillin-sulbactam, or clindamycin (table 2). (See ‘Acute gingivitis’ above.)
• Certain types of severe periodontitis are amenable to systemic antimicrobials in conjunction with mechanical debridement (scaling and root planing) (table 2). This approach has often obviated the need for radical surgical resection of periodontal tissues. For chronic periodontitis, a topical antibiotic approach is used in conjunction with scaling and root planing.(See ‘Periodontitis’ above.)
• The most important therapeutic modality for pyogenic odontogenic infections is surgical drainage and removal of necrotic tissue. Needle aspiration by the extraoral route can be particularly helpful both for microbiologic sampling and for evacuation of pus. The need for definitive restoration or extraction of the infected tooth, the primary source of infection, is usually readily apparent. Deep periodontal scaling and endodontic treatments with root filling is required in most instances. (See ‘Suppurative odontogenic infections’ above.)
• In patients with pyogenic odontogenic infections, in addition to surgical management, antimicrobial agents are generally indicated if fever and regional lymphadenopathy are present, or when infection has perforated the bony cortex and spread into surrounding soft tissue. Ampicillin-sulbactam (3 g intravenously [IV] every six hours) provides extended coverage against oral anaerobes, including those that produce beta-lactamases, and is the treatment of choice in immunocompetent patients (table 3). An alternative is penicillin G (2 to 4 million units IV every four to six hours) in combination with metronidazole (500 mg IV or orally every eight hours). Penicillin-allergic patients should be treated with clindamycin (600 mg IV every eight hours). (See ‘Antibiotic therapy’ above.)
• The single most cost-effective measure for reducing dental caries is fluoridation of public water supplies. Other preventive measures include regular brushing with a fluoridated toothpaste, dental flossing, and reducing the ingestion of sugar-rich foods or beverages. (See ‘Prevention’ above.)
• Recommendations regarding the use of antimicrobial prophylaxis to prevent bacterial endocarditis and prosthetic joint infections in selected patients undergoing dental procedures are presented separately. (See “Antimicrobial prophylaxis for bacterial endocarditis” and “Epidemiology and prevention of prosthetic joint infections”, section on ‘Dental procedures’.)