Pudp Guideline

Prevention of Orthopaedic Implant
Infection in Patients Undergoing Dental

Procedures
Evidence-Based Clinical Practice Guideline
Adopted by:
The American Academy of Orthopaedic Surgeons Board of Directors
December 7, 2012
Please cite this Clinical Practice Guideline as: American Academy of Orthopaedic Surgeons Evidence-
Based Clinical Practice Guideline for the Prevention of Orthopaedic Implant Infections in Patients
Undergoing Dental Procedures aaos.org/dentalcpg Published December 7, 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 ii 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

Description: 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. 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.
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

Description: Evidence from a single low quality study or conflicting findings that do not allow a
recommendation for or against the intervention. An Inconclusive recommendation means that
there is a lack of compelling evidence resulting in an unclear balance between benefits and
potential harm.
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 iii 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

Description: 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. A Consensus recommendation means that expert opinion supports
the guideline recommendation even though there is no available empirical evidence that meets the
inclusion criteria.
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 iv 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 v 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 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
Johns Hopkins Hospital AAOS Staff
Department of Pathology-Microbiology Division William Robert Martin, III, MD
600 N Wolfe Street American Academy of Orthopaedic Surgeons
Meyer B1-193 Medical Director
Baltimore, MD 21287 317 Massachusetts Avenue NE
Washington, D.C. 20002-5769
Knee Society
Kevin Garvin, MD Deborah S. Cummins, PhD
University of Nebraska Medical Center Director, Research and Scientific Affairs
Creighton/Nebraska Health Fund 6300 N. River Road
Department of Orthopaedic Surgery Rosemont, IL 60018
981080 Nebraska Medical Center
Omaha, Nebraska 68198-1080 Sharon Song, PhD
Manager, Clinical Practice Guidelines
Musculoskeletal Infection Society
Douglas R. Osmon, MD
200 1st Street SW Patrick Sluka, MPH
Rochester, MN 55905 Former AAOS Lead Research Analyst
Scoliosis Research Society Kevin Boyer, MPH

Anthony Rinella, MD Former Appropriate Use Criteria Unit Manager
Illinois Spine & Scoliosis Center Former Interim Clinical Practice Guidelines Manager
12701 West 143rd Street, Suite 110
Homer Glen, Illinois 60491 Anne Woznica, MLIS
Medical Research Librarian
Society for Healthcare Epidemiology of America
Angela Hewlett, MD, MS ADA Staff
Assistant Professor, Section of Infectious Diseases Helen Ristic, PhD.
University of Nebraska Medical Center Director, Scientific Information
985400 Nebraska Medical Center ADA Division of Science
Omaha, Nebraska 68198 211 E. Chicago Avenue
Chicago, IL 60611
Guidelines Oversight Chair
Michael J. Goldberg, MD Nicholas Buck Hanson, MPH
Children’s Hospital and Regional Medical Center ADA Lead Research Analyst
1221 1st Avenue, Apt #24E
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 .................................................................................................. iii
Terminology Used in This Guideline........................................................................................... v
Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
Clinical Practice Guideline Work Group .................................................................................. vi
Peer Review Organizations ....................................................................................................... viii
Table of Contents ......................................................................................................................... ix
List of Tables ............................................................................................................................... xii
List of Figures .............................................................................................................................. xv
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
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
Results ................................................................................................................................... 34
Indirect Evidence: Prophylaxis for Dental Procedure Related Bacteremia .............................. 47
Findings................................................................................................................................. 47
Results ................................................................................................................................... 48
Indirect Evidence: Background Microbiology.......................................................................... 55
Findings................................................................................................................................. 55
Results ................................................................................................................................... 56
Recommendations ....................................................................................................................... 74
Recommendation 1 ................................................................................................................... 75
Rationale ............................................................................................................................... 75
Findings................................................................................................................................. 76
Results ................................................................................................................................... 76
Recommendation 2 ................................................................................................................... 85
Rationale ............................................................................................................................... 85
Findings................................................................................................................................. 85
Results ................................................................................................................................... 86
Recommendation 3 ................................................................................................................... 95
Rationale ............................................................................................................................... 95
Findings................................................................................................................................. 95
Future Research ...................................................................................................................... 105
Appendices ................................................................................................................................. 106
Appendix I .............................................................................................................................. 107
Work Group ........................................................................................................................ 107
Clinical Practice Guideline 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
AAOS Clinical Practice Guideline Unit x v0.2 2.2.2012

Studies of Incidence and Prevalence................................................................................... 234
Studies of Prognostics ......................................................................................................... 237
Appendix VI............................................................................................................................ 239
Rules for Opinion Based Consensus Recommendations .................................................... 239
Checklist for Voting on Consensus Recommendations ...................................................... 240
Appendix VII .......................................................................................................................... 241
Voting with the Nominal Group Technique ....................................................................... 241
Appendix VIII ......................................................................................................................... 242
Structured Peer Review Form ............................................................................................. 242
Appendix IX............................................................................................................................ 246
Peer Review ........................................................................................................................ 246
Public Commentary ............................................................................................................ 248
Appendix X ............................................................................................................................. 249
AAOS Bodies That Approved This Clinical Practice Guideline ........................................ 249
Ada Bodies That Approved This Clinical Practice Guideline ............................................ 249
Documentation of Approval ............................................................................................... 250
Appendix XI............................................................................................................................ 251
Supplemental Evidence Tables ........................................................................................... 251
Appendix XII .......................................................................................................................... 263
Quality and Applicability Tables for Included Studies....................................................... 263
Appendix XIII ......................................................................................................................... 306
Conflict of Interest .............................................................................................................. 306
References .................................................................................................................................. 308
AAOS Clinical Practice Guideline Unit xi v0.2 2.2.2012

List of Tables
Table 1 IOM Clinical Practice Guidelines Standards ....................................................................................................7
Table 2 IOM Systematic Review Standards ..................................................................................................................8
Table 3 Relationship between Quality and Domain Scores for Interventions ............................................................. 12
Table 4 Relationship between Applicability and Domain Scores for Interventions .................................................... 13
Table 5 Relationship between Quality and Domain Scores for Incidence and Prevalence Studies ............................. 13
Table 6 Relationship between Applicability and Domain Scores for Incidence and Prevalence Studies .................... 14
Table 7 Relationship between Quality and Domain Scores for Prognostic Studies .................................................... 15
Table 8 Relationship between Applicability and Domain Scores for Prognostic Studies ........................................... 15
Table 9 Strength of Recommendation Descriptions .................................................................................................... 16
Table 10 AAOS Guideline Language .......................................................................................................................... 18
Table 11 High and Low Risk Dental Procedures Defined by Berbari, et al. ............................................................... 26
Table 12 Dental procedures performed and risk of prosthetic hip or knee infection at 6 months and 2 years ............ 26
Table 13 Antibiotic prophylaxis and risk of prosthetic hip or knee infection at 6 months and 2 years ....................... 27
Table 14 Summary of Risk Factor Significance (Proportion of studies that reported significant results) ................... 34
Table 15 Risk Factors for Brushing Bacteremia .......................................................................................................... 37
Table 16 Risk Factors for Chewing Bacteremia .......................................................................................................... 39
Table 17 Risk Factors for Dental Prophylaxis Bacteremia .......................................................................................... 39
Table 18 Risk Factors for Inter-dental Cleaning Bacteremia....................................................................................... 40
Table 19 Risk Factors for Intubation Bacteremia ........................................................................................................ 41
Table 20 Risk Factors for Oral Surgery Bacteremia .................................................................................................... 41
Table 21 Risk Factors for Periodontic Bacteremia ...................................................................................................... 42
Table 22 Risk Factors for Restorative Bacteremia ...................................................................................................... 43
Table 23 Risk Factors for Extraction Bacteremia ........................................................................................................ 44
Table 24 Antibiotic prophylaxis and tooth extraction bacteremia ............................................................................... 48
Table 25 Topical antimicrobials and tooth extraction bacteremia ............................................................................... 52
Table 26 Orthopaedic implant cohort studies .............................................................................................................. 56
Table 27 Orthopaedic implant case series studies ....................................................................................................... 58
Table 28 Direct Comparisons of Antibiotic Prophylaxes for the Prevention of Dental-related Bacteremia ............... 78
Table 29 Indirect (Network) Comparisons of Antibiotic Prophylaxes for the Prevention of Dental-related Bacteremia
..................................................................................................................................................................................... 80
Table 30 Indirect (Network) Significant Comparisons of Antibiotic Prophylaxes for the Prevention of Dental-related
Bacteremia ................................................................................................................................................................... 82
Table 31 Conversion of Odds Ratio from Figure 37 to Number Needed to Treat (NNT) ........................................... 83
Table 32 Network Meta-Analysis Rankings of Antibiotic Prophylaxes for the Prevention of Dental-related
Bacteremia ................................................................................................................................................................... 84
Table 33 Direct Comparisons of Topical Antimicrobial Prophylaxes for the Prevention of Dental-related Bacteremia
..................................................................................................................................................................................... 87
Table 34 Indirect (Network) Comparisons of Topical Antimicrobial Prophylaxes for the Prevention of Dental-related
Bacteremia ................................................................................................................................................................... 89
Table 35 Indirect (Network) Significant Comparisons of Topical Antimicrobial Prophylaxes for the Prevention of
Dental-related Bacteremia ........................................................................................................................................... 91
Table 36 Conversion of Odds Ratio from Figure 40 to Number Needed to Treat (NNT) ........................................... 93
Table 37 Network Meta-Analysis Rankings of Topical Antimicrobial Prophylaxes for the Prevention of Dental-
related Bacteremia ....................................................................................................................................................... 94
Table 38 Summary of Oral Health Related Risk Factor (Proportion of studies that reported significant results) ....... 96
Table 39 Oral Health Related Risk Factors for Brushing Bacteremia ......................................................................... 98
Table 40 Oral Health Related Risk Factors for Chewing Bacteremia ......................................................................... 99
Table 41 Oral Health Related Risk Factors for Dental Prophylaxis Bacteremia ......................................................... 99
Table 42 Oral Health Related Risk Factors for Inter-dental Cleaning Bacteremia .................................................... 100
Table 43 Oral Health Related Risk Factors for Intubation Bacteremia ..................................................................... 101
Table 44 Oral Health Related Risk Factors for Oral Surgery Bacteremia ................................................................. 101
Table 45 Oral Health Related Risk Factors for Periodontic Bacteremia ................................................................... 102
Table 46 Oral Health Related Risk Factors for Restorative Bacteremia.................................................................... 102
Table 47 Oral Health Related Risk Factors for Extraction Bacteremia ..................................................................... 103
AAOS Clinical Practice Guideline Unit xii v0.2 2.2.2012

Table 48 Included Studies for Recommendation 1 .................................................................................................... 131
Table 51 Included Studies for Dental Procedures and Bacteremia ............................................................................ 141
Table 52 Included Studies for Background Microbiology ......................................................................................... 149
Table 53 Excluded Studies for Recommendation 1 ................................................................................................... 158
Table 56 Excluded Studies for Dental Procedures and Bacteremia ........................................................................... 164
Table 57 Excluded Studies for Background Microbiology ....................................................................................... 171
Table 58 Excluded Studies Identified During Full Text Review ............................................................................... 199
Table 59 Antibiotic Prophylaxis Network Meta-Analysis Consistency Check ......................................................... 251
Table 60 Topical Antimicrobial Prophylaxis Network Meta-Analysis Consistency Check ...................................... 252
Table 61 Goodness-of-fit Statistics............................................................................................................................ 253
Table 62 Antibiotic and Topical Antimicrobial Prophylaxis Network Meta-Analysis Consistency Check .............. 253
Table 63 Bacteremia Incidence Study Details ........................................................................................................... 255
Table 64 Bacteremia Prevalence Study Details ......................................................................................................... 257
Table 65 Results of Bacteremia Incidence Random Effects Meta-Analysis ............................................................. 258
Table 66 Results of Bacteremia Prevalence Random Effects Meta-Analysis ........................................................... 258
Table 67 Antibiotic Prophylaxis Studies Not Included in Recommendation 1 Network Meta-analysis ................... 260
Table 68 Topical Antimicrobial Prophylaxis Studies Excluded from Recommendation 2 Network Meta-Analysis 261
Table 69 APPRAISE Table of Prognostic Studies for Recommendation 1, Direct Evidence ................................... 263
Table 70 APPRAISE Table of Treatment Studies for Recommendation 1, Dental Prophylaxis ............................... 263
Table 71 APPRAISE Table of Treatment Studies for Recommendation 1, Intubation ............................................. 264
Table 72 APPRAISE Table of Treatment Studies for Recommendation 1, Oral Surgery ......................................... 265
Table 73 APPRAISE Table of Treatment Studies for Recommendation 1, Periodontology ..................................... 266
Table 74 APPRAISE Table of Treatment Studies for Recommendation 1, Restorative Procedure .......................... 267
Table 75 APPRAISE Table of Treatment Studies for Recommendation 1, Extraction ............................................. 267
Table 76 APPRAISE Table of Treatment Studies for Recommendation 2, Brushing ............................................... 270
Table 77 APPRAISE Table of Treatment Studies for Recommendation 2, Chewing ............................................... 271
Table 78 APPRAISE Table of Treatment Studies for Recommendation 2, Dental Implant ..................................... 271
Table 79 APPRAISE Table of Treatment Studies for Recommendation 2, Dental Prophylaxis ............................... 272
Table 80 APPRAISE Table of Treatment Studies for Recommendation 2, Injection ............................................... 272
Table 81 APPRAISE Table of Treatment Studies for Recommendation 2, Inter-detal Cleaning.............................. 273
Table 82 APPRAISE Table of Treatment Studies for Recommendation 2, Intubation ............................................. 273
Table 83 APPRAISE Table of Treatment Studies for Recommendation 2, Oral Surgery ......................................... 274
Table 84 APPRAISE Table of Treatment Studies for Recommendation 2, Orthodontistry ...................................... 274
Table 85 APPRAISE Table of Treatment Studies for Recommendation 2, Periodontology ..................................... 275
Table 86 APPRAISE Table of Treatment Studies for Recommendation 2, Suture ................................................... 276
Table 87 APPRAISE Table of Treatment Studies for Recommendation 2, Tooth Extraction .................................. 276
Table 88 APPRAISE Table of Prognostic Studies for Recommendation 3, Brushing .............................................. 279
Table 89 APPRAISE Table of Prognostic Studies for Recommendation 3, Chewing .............................................. 280
Table 90 APPRAISE Table of Prognostic Studies for Recommendation 3, Dental Prophylaxis .............................. 281
Table 91 APPRAISE Table of Prognostic Studies for Recommendation 3, Inter-dental Cleaning ........................... 282
Table 92 APPRAISE Table of Prognostic Studies for Recommendation 3, Intubation ............................................ 283
Table 93 APPRAISE Table of Prognostic Studies for Recommendation 3, Oral Surgery ........................................ 284
Table 94 APPRAISE Table of Prognostic Studies for Recommendation 3, Periodontology .................................... 285
Table 95 APPRAISE Table of Prognostic Studies for Recommendation 3, Restorative Procedure.......................... 286
Table 96 APPRAISE Table of Prognostic Studies for Recommendation 3, Tooth Extraction .................................. 287
Table 97 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Brushing ................................. 288
Table 98 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Brushing ................................. 289
Table 99 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Cleft Palate ............................. 290
Table 100 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Dental Implant ...................... 290
Table 101 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Dental Prophylaxis ............... 291
Table 102 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Endodontic............................ 292
Table 103 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Injections .............................. 293
AAOS Clinical Practice Guideline Unit xiii v0.2 2.2.2012

Table 104 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Inter-dental Cleaning ............ 294
Table 105 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Intubation.............................. 295
Table 106 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Oral Surgery ......................... 296
Table 107 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Orthodontic ........................... 297
Table 108 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Periodontology ..................... 298
Table 109 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Restorative Procedure ........... 300
Table 110 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Sialography ........................... 301
Table 111 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Suture ................................... 302
Table 112 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Teething ................................ 303
Table 113 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Tooth Extraction ................... 304
AAOS Clinical Practice Guideline Unit xiv v0.2 2.2.2012

List of Figures
Figure 1 Overview of the Evidence ............................................................................................................................. 25
Figure 2 Incidence of bacteremia by procedure group ................................................................................................ 29
Figure 3 Incidence of bacteremia in single study groups ............................................................................................. 30
Figure 4 Prevalence of bacteremia by group ............................................................................................................... 31
Figure 5 Prevalence of bacteremia in single study groups ........................................................................................... 32
Figure 6 Organisms cultured from cohort studies ........................................................................................................ 57
Figure 7 Organisms cultured from case series studies ................................................................................................. 59
Figure 8 Brushing Bacteria (Incidence) ....................................................................................................................... 60
Figure 9 Brushing Bacteria (Prevalence) ..................................................................................................................... 60
Figure 10 Cleft Palate Bacteria (Prevalence) ............................................................................................................... 61
Figure 11 Dental Implant Bacteria (Incidence) ........................................................................................................... 61
Figure 12 Dental Prophylaxis Bacteria (Incidence) ..................................................................................................... 62
Figure 13 Dental Prophylaxis Bacteria (Prevalence) ................................................................................................... 62
Figure 14 Endodontic Bacteria (Incidence) ................................................................................................................. 63
Figure 15 Endodontic Bacteria (Prevalence) ............................................................................................................... 63
Figure 16 Injection Bacteria (Incidence) ..................................................................................................................... 64
Figure 17 Inter-dental Cleaning Bacteria (Incidence) .................................................................................................. 64
Figure 18 Intubation Bacteria (Incidence) ................................................................................................................... 65
Figure 19 Oral Surgery Bacteria (Incidence) ............................................................................................................... 65
Figure 20 Oral Surgery Bacteria (Prevalence) ............................................................................................................. 66
Figure 21 Orthodontic Bacteria (Incidence) ................................................................................................................ 66
Figure 22 Orthodontic Bacteria (Prevalence) .............................................................................................................. 67
Figure 23 Periodontic [Scaling & Planing] Bacteria (Incidence) ................................................................................ 67
Figure 24 Periodontic [Gingivectomy] Bacteria (Incidence) ....................................................................................... 68
Figure 25 Periodontic [Probing] Bacteria (Incidence) ................................................................................................. 68
Figure 26 Periodontic [Scaling & Planing] Bacteria (Prevalence) .............................................................................. 69
Figure 27 Periodontic [Gingivectomy] Bacteria (Prevalence) ..................................................................................... 69
Figure 28 Periodontic [Probing] Bacteria (Prevalence) ............................................................................................... 70
Figure 29 Sialography Bacteria (Prevalence) .............................................................................................................. 70
Figure 30 Suture Bacteria (Incidence) ......................................................................................................................... 71
Figure 31 Suture Bacteria (Prevalence) ....................................................................................................................... 71
Figure 32 Teething Bacteria (Prevalence) ................................................................................................................... 72
Figure 33 Tooth Extraction Bacteria (Incidence) ........................................................................................................ 72
Figure 34 Tooth Extraction Bacteria (Prevalence) ...................................................................................................... 73
Figure 35 Network Diagram of Antibiotic Prophylaxis for the Prevention of Dental-related Bacteremia .................. 77
Figure 36 Forest Plot of Direct Comparisons of Antibiotics vs. Placebo/No Treatment for the Prevention of Dental-
related Bacteremia ....................................................................................................................................................... 79
Figure 37 Forest Plot of Indirect (Network) Comparisons of Antibiotics vs. Placebo/No Treatment for the Prevention
of Dental-related Bacteremia ....................................................................................................................................... 82
Figure 38 Network Diagram of Topical Antimicrobial Prophylaxes for the Prevention of Dental-related Bacteremia
..................................................................................................................................................................................... 86
Figure 39 Forest Plot of Direct Comparisons of Topical Antimicrobials vs. No Treatment for the Prevention of
Dental-related Bacteremia ........................................................................................................................................... 88
Figure 40 Forest Plot of Indirect (Network) Comparisons of Topical Antimicrobials vs. No Treatment for the
Prevention of Dental-related Bacteremia ..................................................................................................................... 92
AAOS Clinical Practice Guideline Unit xv v0.2 2.2.2012

INTRODUCTION
OVERVIEW
This clinical practice guideline is based on a systematic review of published studies related to the
prevention of orthopaedic implant infection in patients undergoing dental procedures. In addition
to providing practice recommendations, this guideline also highlights gaps in the literature and
areas that require additional research.
This guideline is intended to be used by all appropriately trained physicians and dentists
considering prevention of orthopaedic implant infection in patients undergoing dental
procedures.
GOALS AND RATIONALE

The purpose of this clinical practice guideline is to help improve prevention and treatment based
on the current best evidence. Current evidence-based practice standards demand that physicians
and dentists use the best available evidence in their clinical decision making. To assist them, this
clinical practice guideline consists of a systematic review of the available literature related to the
prevention of orthopaedic implant infection in patients undergoing dental procedures. The
systematic review detailed herein was conducted between October 2010 and July 2011 and
demonstrates where there is good evidence, where evidence is lacking, and what topics future
research could target to improve the prevention of orthopaedic implant infection in patients
undergoing dental procedures. AAOS and ADA staff methodologists and the physician/dentist
work group systematically reviewed the available literature and subsequently wrote the
following recommendations based on a rigorous, standardized process.
We created this guideline as an educational tool to guide qualified physicians and dentists
through a series of treatment decisions in an effort to improve the quality and effectiveness of
care. This guideline should not be construed as including all proper methods of care or excluding
methods of care reasonably directed to obtaining the same results. The ultimate judgment
regarding any specific procedure or treatment must be made in light of all circumstances
presented by the patient and the needs and resources particular to the locality or institution.
INTENDED USERS
This guideline is intended to be used by all qualified clinicians considering prevention of
orthopaedic implant infection in patients undergoing dental procedures. The guideline is intended
to both guide clinical practice and to serve as an information resource for practitioners. An
extensive literature base was considered during the development of this guideline. In general,
practicing clinicians do not have the resources necessary for such a large project. The AAOS and
ADA hope that this guideline will assist practitioners not only in making clinical decisions about
their patients, but also in describing, to patients and others, why the chosen treatment represents
the best available course of action.
In the interest of collegiality, the ADA elected to follow the rigorous AAOS process for
development of this clinical guideline. This guideline is not intended for use as a benefits
determination document. Making these determinations involves many factors not considered in
the present document, including available resources, business and ethical considerations, and
needs.
AAOS Clinical Practice Guideline Unit 1 v0.2 2.2.2012

Evidence for the effectiveness of health-care services is not always present. This is true
throughout all areas of medicine and dentistry. Accordingly, all users of this clinical practice
guideline are cautioned that an absence of evidence is not evidence of ineffectiveness. An
absence means just that; there are no data. It is the AAOS position that rigorously developed
clinical practice guidelines should not seek to guide clinical practice when data are absent unless
the disease, disorder, or condition in question can result in loss of life or limb. The AAOS
incorporates expert opinion into a guideline under these circumstances, and only under these
circumstances. Accordingly, when the AAOS states that it cannot recommend for or against a
given intervention or service, it is stating that currently available data do not provide clear
guidance on which course of action is best, and that it is therefore reluctant to make a
recommendation that has potentially national ramifications. The AAOS and ADA believe that
when evidence is absent, it is particularly important for treatment decisions to be based on
mutual communication between the patient, physician and dentist, with discussion of available
treatments and procedures applicable to that patient, and with consideration of the natural history
of the disease, costs versus benefits, and current practice patterns. Once the patient has been
informed of available therapies and has discussed these options with his/her physician and/or
dentist, an informed decision can be made.
PATIENT POPULATION
This document addresses the prevention of orthopaedic implant infection in patients undergoing
dental procedures.
BURDEN OF DISEASE AND ETIOLOGY

Approximately 200,000 primary total hip arthroplasties and 400,000 primary total knee
arthroplasties were performed in the United States in 2003, with a projected increase to 380,000
hip procedures and over 1,500,000 knee procedures in 2020.1 Orthopaedic implant infection rates
range from 0.3% to 8.3% in the published literature (see Table 26). These infections can be
caused by entry of organisms into the wound during surgery, hematogenous spread, recurrence
of sepsis in a previously infected joint, or contiguous spread of infection from a local source.2
POTENTIAL HARMS, BENEFITS, AND CONTRAINDICATIONS

The goal of prevention of orthopaedic implant infection in patients undergoing dental procedures
is avoidance of serious complications resulting from orthopaedic implant infection. Most
treatments are associated with some known risks. In addition, contraindications vary widely
based on the treatment administered. Therefore, discussion of available treatments applicable to
the individual patient rely on mutual communication between the patient, dentist and physician,
weighing the potential risks and benefits for that patient.

PREVENTING BIAS IN AN AAOS CLINICAL PRACTICE
GUIDELINE
Clinical practice guidelines (CPGs) have come under scrutiny because many of them are not
objective. Shaneyfelt and Centor have noted that most current guidelines are not at all like those
the Institute of Medicine (IOM) had originally intended, and that they have strayed so far from
this original concept that they are mere consensus reports.3 More recently, the IOM has stated
that “the quality of CPG development processes and guideline developer adherence to quality
standards have remained unsatisfactory and unreliable for decades.”4 The AAOS understands
that only high quality guidelines are credible, and we go to great lengths to ensure the integrity of
our guidelines. The purpose of this section is to highlight the processes whereby the AAOS
accomplishes this. Additional details about how we combat bias also appear in the Methods
section of this guideline.
The AAOS combats bias beginning with the selection of work group members. Applicants for
AAOS development work groups who have financial conflicts of interest (COI) related to the
guideline topic cannot participate on an AAOS work group if they currently have, or have had a
relevant conflict within a year of the start date of guideline development. Applicants also cannot
participate if one of their immediate family members has, or has had a relevant conflict of
interest.
Financial COI are not the only COI that can influence a guideline. The IOM has noted that
income source, long service on government committees or with private insurers, authorship of
articles on guideline-related subjects, and biases from personal experience can also cause bias.5
This suggests that those with the greatest expertise in any given topic area are also those most
likely to introduce bias into guideline development. It also suggests that bias can only be
counteracted by processes that are in place throughout the entirety of the development, and not
just at the beginning.
One manner whereby the AAOS combats bias throughout guideline development is by having a
team that is free of all of the above-mentioned COI conduct the literature searches, evaluate the
quality of the literature, and sythesize the data (see Appendix I for a list of the work group
members and methodologists who participated in the development of this guideline). Hirsh and
Guyatt have suggested that using such conflict-free methodologists is critical to developing an
unbiased guideline.6
Our use of methodologists changes the traditional role of clinicians in guideline development.
The clinicians on an AAOS guideline work group serve as content experts. One of the clinicians’
tasks is to frame the scope of the guideline by developing preliminary recommendations (these
are the questions that will be addressed by the guideline; see below for further information).
Another is to develop the article inclusion criteria. After they have done so, the AAOS medical
librarian obtains key words from work group members and uses words, the preliminary
recommendations, and inclusion criteria to construct literature search strategies. Clinicians are
not permitted to suggest specific articles for inclusion at this time inasmuch as those suggestions
are often about articles they have authored or that support a particular point of view.

Methodologists then determine which articles should be recalled and whether a recalled article
meets the inclusion criteria. After completing this task, the clinician work group is given a list of
the recalled articles that are proposed for inclusion and a list of the recalled studies proposed for
exclusion. The work group then reviews these lists and suggests modifications. The purpose of
this step is to assure the integrity of the guideline’s data set. The methodologists are not
obligated to take the work group’s suggestions, but they are obligated to explain why they did
not. Articles included or excluded as a result of this clinician review are handled as all other
included articles or excluded studies. The methodologists also appraise the quality and
applicability of each included study (we use “quality” as synonymous with “risk of bias.” The
latter term is preferred by others but, since quality and risk of bias are measured exactly the same
way, the difference between the two seems largely semantic. Similarly, we use the terms
“applicability” and “generalizability” as synonyms.)
Quality appraisal is a subject worth special mention because it is a necessary step in performing a
systematic review and in developing a clinical practice guideline. One evaluates the quality (or
risk of bias) of a study to determine how “believable” its results are, the results of high quality
studies are more believable than those of low quality studies. This is why, all other things being
equal, a recommendation based on high quality evidence will receive a higher grade than
recommendations based on lower quality evidence (see Grades of Recommendation for more
information). Biases in quality evaluation can cause overestimates of the confidence one should
have in available data, and in a guideline recommendation.
Bias in quality evaluation arises when members of a work group view the papers they authored
as being more believable than similar research performed by others, view certain studies as more
believable simply because they were conducted by thought leaders in a given medical specialty
area, and/or view research results that they are “comfortable” with to be more believable than
results with which they are uncomfortable.
The problem of biased quality evaluations is aggravated by the fact that no method for
quality/risk of bias assessment has been empirically validated. Ultimately, therefore, all methods
of quality/risk of bias assessment, are based on expert opinion (including those based on expert
consensus obtained through formal methods like the Delphi method), and they all require
judgments that are arbitrary. The method we use is no exception.
Given that all currently available quality evaluation systems are imperfect their susceptibility to
bias must be a deciding factor about whether to use them in clinical practice guideline
development. The AAOS methodology is guided by the thinking that, if guideline developers
have the choice between several methodologically imperfect systems, the least biased system is
the best. The burden that falls to readers of clinical practice guidelines is to determine which
systems are not. Making this determination requires readers to examine two aspects of quality
evaluation; the individual criteria used to evaluate a study, and how those criteria are translated
into a final determination of a study’s believability.
The criteria used to evaluate a study are often framed as one or more questions about a study’s
design and/or conduct. At the AAOS, independent methodologists answer these questions. This
combats bias by virtually eliminating the intellectual conflicts of interest that can arise when
others are providing the answers.

Also preventing bias is the way the quality questions are phrased, and the fact that there are
specific criteria (described in almost 300 pages of documentation) for answering each question.
The simplest example, the AAOS question “Was there >80% follow-up” illustrates the point.
The question is answered “Yes,”, “No”, or “Unclear.” To determine whether a “Yes” or “No”
answer is unclear, the methodologist merely looks at the number of patients present at the
follow-up time of interest, the number of patients present at the start of the study, and expresses
the former as a percentage of the latter. If the article does not report the information required to
compute this percentage (or does not directly report the percentage) an “Unclear” answer is
supplied. In answering this or any other question in the AAOS quality assessment scheme, the
methodologist is merely checking to see if the article provides specific data or makes specific
statements. If it does, a “Yes” or “No” answer is supplied. If it does not, an “Unclear” answer is
given. This lack of ambiguity in the criteria required to answer each question makes answering
each question an almost completely objective exercise.
This stands in sharp contrast to the use of Levels of Evidence systems (also called evidence
hierarchies), which are probably the most commonly used way of evaluating study quality in
clinical practice guideline development. The vagueness of these systems opens the opportunity
for bias. For example, these systems often hold that Level I evidence (i.e., the highest quality
evidence) is from a well-designed randomized controlled trial, without ever specifying what
“well-designed” means. This lack of specific instructions creates the possibility for bias in
grading articles because it allows for an ad hoc appraisal of study quality. Furthermore, there are
over 50 such systems, individuals do not consistently apply any given system in the same way,
many are not sensible to methodologists,7and Level I studies, those of the highest level of
evidence, do not necessarily report that they used adequate safeguards to prevent bias.8
Obviously, simply answering a series of questions about a study does not complete the quality
evaluation. All clinical practice guideline developers then use that information to arrive at a final
characterization of a study’s quality. This can be accomplished in two (and only two) ways, by
allowing those who are performing this final characterization to use their judgment, or by not
letting them do so. Bias is possible when judgment is allowed. Bias is mitigated in the AAOS
system because the final rating is accomplished entirely by a computer that uses a pre-
determined algorithm.
This aspect of the AAOS system contrasts with the GRADE system,9 which places the final
determination about whether a study has “no”, “serious” or “very serious” limitations in the
hands of the reviewer. Furthermore, the GRADE system allows the investigator to specify “other
sources of bias” (i.e. sources of bias that were not specified a priori) and, although this is a
theoretically sound way to approach quality evaluation, in practice it too, could allow for ad hoc
criticisms of a study, and to criticisms that are not evenly applied across all studies. We
recognize that we may miss some uncommon study flaws in our evaluation. While this means
that our quality evaluation system is not perfectly comprehensive, it does not mean that it is
biased. This is yet another example of how the AAOS, faced with a choice among imperfect
quality/risk of bias systems, chooses the least biased approach. Given the above mentioned
history of guideline development, the AAOS emphasis on elimination of bias seems prudent.
The AAOS system, unlike the GRADE system, also specifically addresses the issue of statistical
power (i.e., number of patients enrolled) of a trial. Low statistical power is a common problem in

the medical literature,10 and low power studies can lead reviewers to incorrectly conclude that a
statistically non-significant result means that a given treatment does not work or, perhaps more
serious, to reach positive conclusions about an intervention based on the putative “trends”
reported in such studies. We regard low power studies as uninformative, and do not consider
them when formulating a final recommendation. (We do, however, include low power studies in
meta-analyses, inasmuch as one purpose of a meta-analysis is to overcome the low power of
individual studies.)
Like the GRADE system, the AAOS guidelines will include observational studies. However, we
do not always do so. Rather, we perform “best evidence” syntheses in AAOS guidelines in which
we examine the best available (as opposed to the best possible) evidence. We use the best
evidence because it is more “believable” than other evidence. The results of studies that are more
believable should not be modified by results that are less believable.
When an AAOS guideline includes uncontrolled studies (e.g., case series) it only includes
prospective case series that meet a number of other quality-related criteria. We do not include
retrospective case series under any circumstances. Such studies do not establish empirically
testable comparisons or relationships a priori, are not based on systematic assignment of patients
to treatment groups, and are not designed to fully control measurement bias. There is no specific
prohibition against using such studies in the GRADE system. We suggest that all guideline
developers who are attempting to produce unbiased guidelines employ similar a priori criteria to
specify the point at which they consider evidence to be too unreliable to consider.
Also unlike the GRADE system, the AAOS guidelines make provisions for making
recommendations based on expert opinion. This recognizes the reality of medicine, wherein
certain necessary and routine services (e.g., a history and physical) should be provided even
though they are backed by little or no experimental evidence, and wherein certain diseases,
disorders, or conditions are so grave that issuing a recommendation in the absence of evidence is
more beneficial to patients than not issuing one. To prevent the bias that can result when
recommendations based on expert opinion proliferate, we have specific rules for when opinion-
based recommendations can be issued (further discussed below) and, perhaps more important,
for when they cannot be issued. The AAOS will only issue an opinion-based recommendation
when the service in question has virtually no associated harms and is of low cost (e.g., a history
and physical) or when the consequences of doing (or not doing) something are so catastrophic
that they will result in loss of life or limb.
Clinical practice guidelines have not met quality standards for a long time. In recognition of this,
the IOM has developed two checklists, one for systematic reviews11 and another for clinical
practice guidelines.4 Meeting the items on these checklists should assure readers of a guideline
that it is unbiased. Table 1 and Table 2 show the performance of the present AAOS guideline on
these standards.

Table 1 IOM Clinical Practice Guidelines Standards
AAOS Guideline Meets
IOM Guidelines Standard Standard ?
Establishing transparency Yes
Management of Conflict of Interest Yes
No – AAOS does not involve

Guideline development group composition
patient representative
Clinical practice guideline – systematic review
Yes
intersection
Establishing evidence foundations for and rating
Yes
strength of recommendations
Articulation of recommendations Yes
External review Yes
Updating Yes

Table 2 IOM Systematic Review Standards
AAOS Systematic Reviews Meet
IOM Systematic Review Standard Standard ?
Establish a team with appropriate expertise and experience to
Yes
conduct the systematic review
Manage bias and conflict of interest (COI) of the team conducting
Yes
the systematic review
Ensure user and stakeholder input as the review is designed and
Yes
conducted
Manage bias and COI for individuals providing input into the
Yes
systematic review
Formulate the topic for the systematic review Yes
Develop a systematic review protocol Yes
No – do not have peer review of
Submit the protocol for peer review
protocol
Make the final protocol publicly available, and add any amendments
Yes
to the protocol in a timely fashion
Conduct a comprehensive systematic search for evidence Yes
Take action to address potentially biased reporting of research No – do not search for
results unpublished information
Screen and select studies Yes
Document the search Yes
Manage data collection Yes
Critically appraise each study Yes
Use a prespecified method to evaluate the body of evidence Yes
Conduct a qualitative synthesis Yes
Decide if, in addition to a qualitative analysis, the systematic review
Yes
will include a quantitative analysis (meta-analysis)
If conducting a meta-analysis, then do the following: Yes
Prepare final report using a structured format Partially - no lay public summary
Partially - do not use independent
Peer review the draft report third party to manage peer
review process
Publish the final report in a manner that ensures free public access Yes

METHODS
To develop this guideline, the AAOS-ADA work group held an introductory meeting on
November 20 and 21, 2010 to establish the scope of the guideline and the systematic reviews.
Upon completing the systematic reviews, the work group participated in a two-day
recommendation meeting on October 15 and 16, 2011 at which time the final recommendations
and rationales were edited, written, and voted on.
FORMULATING PRELIMINARY RECOMMENDATIONS

The work group determined the scope of the guideline by constructing a set of preliminary
recommendations. These recommendations specify [what] should be done in [whom], [when],
[where], and [how often or how long]. This is similar to the PICO (patients, interventions,
comparisons, and outcomes) format used when the scope of a guideline is framed using key
questions instead of preliminary recommendations. The preliminary recommendations function
as questions for the systematic reviews that underpin each preliminary recommendation, not as
final recommendations or conclusions. To avoid “wordsmithing” discussions at the initial work
group meeting, the preliminary recommendations are always worded as recommending for
something. Appendix II describes the formulation of preliminary recommendations in further
detail.
Once established, these preliminary recommendations cannot be modified until the final work
group meeting. At this time, they can only be modified in accordance with the available evidence
and only in accordance with the AAOS rules for how the wording of a recommendation depends
on the grade of recommendation (see below for information about this wording). No
modifications of the preliminary recommendations can require new literature searches and, at the
final work group meeting, no recommendations can be added that require the use of expert
opinion.
FULL DISCLOSURE INFORMATION

All of the work group’s preliminary recommendations are represented in this guideline. This
ensures full disclosure of the information that the AAOS-ADA work group examined, and
assures readers that they are seeing all the information, and not just a selected portion of it.
STUDY SELECTION CRITERIA

We developed a priori article inclusion criteria for the systematic reviews for each preliminary
recommendation. These criteria are our “rules of evidence.” Articles that did not meet them are,
for the purposes of this guideline, not evidence.
To be included in our systematic reviews (and hence, in this guideline) an article had to be a
report of a study that:
 Study must be of patient population of interest (as described by preliminary

recommendations)
 Study must report on >50% of the patient population of interest if results are combined
 Article must be a full article report of a clinical study
 Study must appear in a peer-reviewed publication
 Study must be published in English

 Study must be of humans
 Study must not be an in vitro study
 Study must not be a biomechanical study
 Study must not have been performed on cadavers
 Study must be published in or after 1960
 Study results must be quantitatively presented
 Retrospective case series, medical records review, meeting abstracts, historical articles,
editorials, letters, and commentaries are excluded
 Registry data is included
 Case series studies that give patients the treatment of interest AND another treatment are
excluded
 Case series studies that have non-consecutive enrollment of patients are excluded
 Study should have 10 or more patients per group
 Composite measures or outcomes, even if they are patient-oriented, are excluded
The restriction on English language papers is unlikely to influence the recommendations in the
present clinical practice guideline. An umbrella review of systematic reviews on language
restriction found that none of the systematic reviews provided empirical evidence that excluding
non-English language studies resulted in biased estimates of an intervention’s effectiveness.12
We did not include systematic reviews or meta-analyses conducted by others, or guidelines

developed by others. These documents are developed using different inclusion criteria than those
specified by the AAOS-ADA work group. Therefore, they may include studies that do not meet
our inclusion criteria. We recalled these documents if their abstract suggested that they might
address one of our recommendations, and we searched their bibliographies for additional studies.
LITERATURE SEARCHES
We searched for articles published from January 1966 to July 25, 2011. We searched three
electronic databases; PubMed, EMBASE, and The Cochrane Central Register of Controlled
Trials. Strategies for searching electronic databases were constructed by the AAOS Medical
Librarian using previously published search strategies to identify relevant studies.13-18
We supplemented searches of electronic databases with manual screening of the bibliographies

of all retrieved publications. We also searched the bibliographies of recent systematic reviews
and other review articles for potentially relevant citations. All articles identified were subject to
the study selection criteria listed above. As noted above, the guideline work group also examined
lists of included and excluded studies for errors and omissions.
We went to these lengths to obtain a complete set of relevant articles. Having a complete set
ensures that our guideline is not based on a biased subset of articles. The study attrition diagram
in Appendix III provides details about the inclusion and exclusion of the studies considered for
this guideline. The search strategies used to identify these studies are provided in Appendix IV.
BEST EVIDENCE SYNTHESIS

We included only the best available evidence for any given outcome addressing a
recommendation. Accordingly, we first included the highest quality evidence for any given

outcome if it was available. In the absence of two or more studies that reported an outcome at
this quality, we considered studies of the next lowest quality until at least two or more
occurrences of an outcome had been acquired. For example, if there were two “Moderate”
quality studies that reported an outcome, we did not include “Low” quality studies that also
reported this outcome, but if there was only one “Moderate” quality study that reported an
outcome, we also included “Low” quality studies.
APPRAISING EVIDENCE QUALITY AND APPLICABILITY

STUDIES OF INTERVENTIONS
QUALITY
As noted earlier, we judged quality using questions specified before this guideline topic was
selected, and a computer program determined the final quality rating. Accordingly, it is highly
unlikely that bias affected our determinations of quality.
We separately evaluated the quality of evidence for each outcome reported by each study. This
follows the suggestion of the GRADE working group and others.9, 19 We evaluated quality using
a domain-based approach. Such an approach is used by the Cochrane Collaboration.20 Unlike the
Cochrane Collaboration’s scheme, our scheme allows for evaluation of studies of all designs.
The domains we used are whether:
 The study was prospective (with prospective studies, it is possible to have an a priori
hypothesis to test; this is not possible with retrospective studies.)
 The study was of low statistical power
 The assignment of patients to groups was unbiased
 There was blinding to mitigate against a placebo effect
 The patient groups were comparable at the beginning of the study
 The intervention was delivered in such a way that any observed effects could reasonably
be attributed to that intervention
 Whether the instruments used to measure outcomes were valid
 Whether there was evidence of investigator bias
Each quality domain is addressed by one or more questions that are answered “Yes,” ”No,” or
“Unclear.” These questions and the domains that each address are shown in Appendix V.
To arrive at the quality of the evidence for a given outcome, all domains except the “Statistical
Power” domain are termed as “flawed” if one or more questions addressing any given domain
are answered “No” for a given outcome, or if there are two or more “Unclear” answers to the
questions addressing that domain. The “Statistical Power” domain is considered flawed if a given
study did not enroll enough patients to detect a standardized difference between means of 0.2.
Domain flaws lead to corresponding reductions in the quality of the evidence. The manner in
which we conducted these reductions is shown in Table 3. For example, the evidence reported in
a randomized controlled trial (RCT) for any given outcome is rated as “High” quality if zero or
one domain is flawed. If two or three domains are flawed for the evidence addressing this
outcome, the quality of evidence is reduced to “Moderate,” and if four or five domains are

flawed, the quality of evidence is reduced to “Low.” The quality of evidence is reduced to “Very
Low” if six or more domains are flawed.
Some flaws are so serious that we automatically term the evidence as being of “Very Low”
quality, regardless of a study’s domain scores. These serious design flaws are:
 Non-consecutive enrollment of patients in a case series

 Case series that gave patients the treatment of interest AND another treatment
 Measuring the outcome of interest one way in some patients and measuring it in another
way in other patients
 Low statistical power
Table 3 Relationship between Quality and Domain Scores for Interventions

Number of Flawed Domains Quality
0-1 High
2-3 Moderate
4-5 Low
>5 Very Low
Although we mention levels of evidence in this guideline, we do so only to provide some very
general information about study quality to those readers familiar with the levels of evidence
system of The Journal of Bone and Joint Surgery - American. However, for the reasons noted
above, we do not use levels of evidence as when we speak of “quality” in this document, and
levels of evidence play no role in our determination of the grade of the final recommendations.
APPLICABILITY
We rated the applicability (also called “generalizability” or “external validity”) of the evidence
for each outcome reported by each study. As with quality, applicability ratings were determined
by a computer program that used predetermined questions about specific applicability domains.
We rated applicability as either “High”, “Moderate”, or “Low” depending on how many domains
are flawed. As with quality, a domain is “flawed” if one or more questions addressing that
domain is answered “No” or if two or more are answered “Unclear.” We characterized a domain
as “flawed” if one or more questions addressing any given domain are answered “No” for a
given outcome, or if there are two or more “Unclear” answers to the questions addressing that
domain (see Appendix V for the specific applicability questions we employed and the domains
that each question addresses).
Our questions and domains about applicability are those of the PRECIS instrument.21 The
instrument was originally designed to evaluate the applicability of randomized controlled trials,
but it can also be used for studies of other design. The questions in this instrument fall into four
domains. These domains and their corresponding questions are shown in Appendix V. As shown
in Table 4, the applicability of a study is rated as “High” if it has no flawed domains, as “Low” if
all domains are flawed, and as “Moderate” in all other cases.

Table 4 Relationship between Applicability and Domain Scores for Interventions
Number of Flawed Domains Applicability
0 High
1, 2, 3 Moderate
4 Low
STUDIES OF INCIDENCE AND PREVALENCE

QUALITY
As with our appraisal of the quality of studies of intervention, our appraisal of studies of
incidence and prevalence is a domain-based approach conducted using a priori questions (please
see Appendix V for the questions we used and the domains to which they apply), and scored by a
computer program. The four domains we employed are listed below:
 Outcome (whether the study is measuring the incidence/prevalence of a clinically

meaningful event)
 Measurement (whether the study measured the disease/disorder/condition in a way that
would lead to accurate estimates of incidence or prevalence)
 Participants (whether those who were studied were representative of the population of
interest)
 Investigator Bias (whether author biases could have prejudiced the results)
We characterized a study that has no flaws in any of its domains as being of “High” quality, a
study that has one flawed domain as being of “Moderate” quality, a study with two flawed
domains as being of “Low” quality, and a study with three or more flawed domains as being of
“Very Low” quality (Table 5).We characterized a domain as “flawed” if one or more questions
addressing any given domain are answered “No” for a given screening/diagnostic/test, or if there
are two or more “Unclear” answers to the questions addressing that domain.
We considered some design flaws as so serious that their presence automatically guarantees that
a study is characterized as being of “Very Low” quality regardless of its domain scores. These
flaws are:
 The outcome of interest could have occurred more than once in a person during the
course of the study, and more than the first episode of the outcome was counted in the
incidence/prevalence estimate
 The study was a study of the proportion (or number) of people who have a disease, and
the study was not a study of point prevalence.
Table 5 Relationship between Quality and Domain Scores for Incidence and Prevalence
Studies
0 High
1 Moderate
2 Low
≥3 Very Low

APPLICABILITY
We separately evaluated the applicability of prevalence and incidence studies, and did so using a
domain-based approach (please see Appendix V for the relevant questions and the domains they
address) that involves predetermined questions and computer scoring. The domains we used for
the applicability of prognostics are:
 Participants (i.e. whether the participants in the study were like those seen in the
population of interest)
 Analysis (i.e., whether participants were appropriately included and excluded from the
analysis)
 Outcome (i.e., whether the incidence/prevalence estimates being made were of a
clinically meaningful outcome)
We characterized a domain as “flawed” if one or more questions addressing any given domain
are answered “No” for a given screening/diagnostic/test, or if there are two or more “Unclear”
answers to the questions addressing that domain. We characterized the applicability of a
screening/diagnostic test as “High” if none of its domains are flawed, “Low” if all of its domains
are flawed, and “Moderate” in all other cases (Table 6).
Table 6 Relationship between Applicability and Domain Scores for Incidence and
Prevalence Studies
0 High
1,2 Moderate
3 Low
STUDIES OF PROGNOSTICS
QUALITY
Our appraisal of studies of prognostics is a domain-based approach conducted using a priori
questions, and scored by a computer program (please see Appendix V for the questions we used
and the domains to which they apply). The six domains we employed are:
 Prospective (A variable is specified as a potential prognostic variable a priori. This is not

possible with retrospective studies.)
 Power (Whether the study had sufficient statistical power to detect a prognostic variable
as statistically significant)
 Analysis (Whether the statistical analyses used to determine that a variable was rigorous
to provide sound results)
 Model (Whether the final statistical model used to evaluate a prognostic variable
accounted for enough variance to be statistically significant)
We separately determined a quality score for each prognostic reported by a study. We

characterized the evidence relevant to that prognostic variable as being of “High” quality if there
are no flaws in any of the relevant domains, as being of “Moderate” quality if one of the relevant

domains is flawed, as “Low” quality if there are two flawed domains, and as “Very Low” quality
if three or more relevant domains are flawed (Table 7). We characterized a domain as “flawed” if
one or more questions addressing any given domain are answered “No” for a given prognostic
variable, or if there are two or more “Unclear” answers to the questions addressing that domain.
Table 7 Relationship between Quality and Domain Scores for Prognostic Studies
0 High
1 Moderate
2 Low
≥3 Very Low
APPLICABILITY
We separately evaluated the applicability of each prognostic variable reported in a study, and did
so using a domain-based approach (please see Appendix V for the relevant questions and the
domains they address) that involves predetermined questions and computer scoring. The domains
we used for the applicability of prognostics are:
 Patients (i.e. whether the patients in the study and in the analysis were like those seen in
clinical practice)
 Analysis (i.e., whether the analysis was not conducted in a way that was likely to describe
variation among patients that might be unique to the dataset the authors used)
 Outcome (i.e., whether the prognostic was a predictor of a clinically meaningful
outcome)
We characterized the evidence relevant to that prognostic as being of “High” applicability if

there are no flaws in any of the relevant domains, as being of “Low” applicability if all three
domains are flawed, and as of “Moderate” applicability in all other cases (Table 8). We
characterized a domain as “flawed” if one or more questions addressing any given domain are
answered “No” for a given prognostic variable, or if there are two or more “Unclear” answers to
the questions addressing that domain.
Table 8 Relationship between Applicability and Domain Scores for Prognostic Studies
0 High
1,2 Moderate
3 Low
OTHER BIASES IN THE PUBLISHED LITERATURE

Despite our efforts to rigorously evaluate the quality of the studies we included, there remains
the possibility that some of the articles considered in this guideline are biased. A 2007 umbrella
review found that 20 of 23 previous systematic reviews found a positive relationship between
pharmaceutical industry support and pro-industry findings,22 leading the author to conclude that
“it is unequivocally the case that sponsorship influences published results.” The relationship also
seems to exist in orthopaedics, where authors of industry-funded studies of hip and knee

arthroplasty come to positive conclusions more often that authors of studies not funded by
industry,23 and where the association between trial outcome and funding source exists across
subspecialty societies.24
These apparent biases may not be related to the article’s quality22 and, therefore, may not be
detected by our evaluations or the quality/risk of bias evaluations performed by others.
Accordingly, we follow the suggestion of Montori, et al.25 and do not use the conclusions of the
authors of any article. Rather, we use only the information provided in an article’s Methods
section and in its Results section. Furthermore, we perform our analysis using network meta-
analysis, an analytical technique that considers the full range of alternatives rather than just those
comparisons selected by industry.26
GRADES OF RECOMMENDATION
A grade of recommendation expresses the degree of confidence one can have in each of the final
recommendations. Grades express how likely it is that a recommendation will be overturned by
future evidence, and are termed “Strong,” “Moderate,” or “Limited.”
We used the above-discussed quality and applicability ratings in conjunction with consistency,
whether the studies reported outcomes that the work group deemed “critical,” and the potential
for catastrophic harm to determine the final grade of recommendation. More specifically, we
began by setting the grade as equal to the quality of the available evidence. In other words, high
quality evidence is preliminarily taken as a “Strong” grade, moderate quality as a “Moderate”
grade, and low quality as a “Limited” grade. As noted above, very low quality evidence is not
included in AAOS guidelines. Accordingly, the final versions of preliminary recommendations
that are based on such evidence will either state that the AAOS cannot recommend for or against
a given medical service or, assuming that the requirements for a recommendation based on
expert opinion are met it will be a consensus-based recommendation. We then adjusted the grade
down one step if the evidence is of “Low” applicability, is inconsistent (defined as studies that
report qualitatively different effects, a heterogeneous meta-analysis, or a network meta-analysis
with statistically significant inconsistency), if there is only one study that addresses a given
recommendation, or if a majority of the outcomes deemed “critical” are not reported in the
literature. Preliminary grades were adjusted upwards if the evidence is of “High” applicability or
if providing the intervention decreases the potential for catastrophic harm (loss of life or limb).
Preliminary grades were adjusted downward if the evidence is of “Low” applicability or if the
medical service in question is accompanied with catastrophic harm.
For a recommendation of a “Strong” grade, a minimum of two high quality studies are needed. A
minimum of two moderate quality studies are required for a “Moderate” grade, and a minimum
of two low quality studies are needed for a “Limited” grade. Recommendations addressed by
only very low quality studies are consensus-based.
Table 9 Strength of Recommendation Descriptions

Statement
Rating Description of Evidence Strength Implication for Practice
Strong Evidence is based on two or more “High” Practitioners should follow a Strong
strength studies with consistent findings recommendation unless a clear and
for recommending for or against the compelling rationale for an
intervention. alternative approach is present.
A Strong recommendation means that

the benefits of the recommended
approach clearly exceed the potential
harm (or that the potential harm clearly
exceeds the benefits in the case of a
strong negative recommendation), and
that the strength of the supporting
evidence is high.
Moderate Evidence from two or more “Moderate” Practitioners should generally follow
strength studies with consistent findings, a Moderate recommendation but
or evidence from a single “High” quality remain alert to new information and
study for recommending for or against be sensitive to patient preferences.
the intervention.
A Moderate recommendation means that

the benefits exceed the potential harm (or
that the potential harm clearly exceeds
the benefits in the case of a negative
recommendation), but the strength of the
supporting evidence is not as strong.
Limited Evidence from two or more “Low” Practitioners should be cautious in

strength studies with consistent findings, deciding whether to follow a
or evidence from a single Moderate recommendation classified as
quality study recommending for or Limited, and should exercise
against the intervention or diagnostic. judgment and be alert to emerging
publications that report evidence.
A Limited recommendation means the Patient preference should have a
quality of the supporting evidence that substantial influencing role.
exists is unconvincing, or that well-
conducted studies show little clear
advantage to one approach versus
another.

Inconclusive Evidence from a single low quality study Practitioners should feel little
or conflicting findings that do not allow a constraint in deciding whether to
recommendation for or against the follow a recommendation labeled as
intervention. Inconclusive and should exercise
judgment and be alert to future
An Inconclusive recommendation means publications that clarify existing
that there is a lack of compelling evidence for determining balance of
evidence resulting in an unclear balance benefits versus potential harm.
between benefits and potential harm. Patient preference should have a
substantial influencing role.
Consensus1 The supporting evidence is lacking and Practitioners should be flexible in
requires the work group to make a deciding whether to follow a
recommendation based on expert opinion recommendation classified as
by considering the known potential harm Consensus, although they may set
and benefits associated with the boundaries on alternatives. Patient
treatment. preference should have a substantial
influencing role.
A Consensus recommendation means
that expert opinion supports the guideline
recommendation even though there is no
available empirical evidence that meets
the inclusion criteria.
1
The AAOS will issue a consensus-based recommendation only when the service in question has virtually no associated harm
and is of low cost (e.g. a history and physical) or when not establishing a recommendation could have catastrophic consequences.
WORDING OF THE FINAL RECOMMENDATIONS

To prevent biased nuances in the way recommendations are worded, the AAOS uses
predetermined, specific language for its recommendations. The exact wording is governed by the
final grade of the recommendation. This wording, and the corresponding grade, is shown in
Table 10.
Table 10 AAOS Guideline Language

Guideline Language Grade of Recommendation
We recommend Strong
We suggest Moderate
The Practitioner might Limited
We are unable to recommend for or against Inconclusive
In the absence of reliable evidence, the opinion of
Consensus*
this work group is*
1
The AAOS will issue a consensus-based recommendation only when the service in question has virtually no associated harm
and is of low cost (e.g. a history and physical) or when not establishing a recommendation could have catastrophic consequences.

*Consensus based recommendations are made only if specific criteria are met (see below).
CONSENSUS RECOMMENDATIONS
Consensus recommendations are recommendations based on expert opinion. As noted above,
there are times when it is prudent to make such recommendations. However, liberal use of them
can allow for bias. Accordingly, we allow consensus-based recommendations using the
procedures described by the United States Preventative Services Task Force (USPSTF).27 In
effect, this means that the AAOS will only issue a consensus-based recommendation under two
circumstances. The first is for procedures that have virtually no associated harms, are of
relatively low cost, and that reflect current, routine clinical practice. The second is when
providing (or not providing) a service could result in loss of life or limb. Because they are based
on expert opinion, consensus recommendations are the weakest type of recommendation.
In making such recommendations, the AAOS instructs its clinician work group members to
address:
 The potential preventable burden of disease (if the burden is low, a consensus-based
recommendation cannot be issued)
 Potential harms (if there are serious harms that result from providing a medical service, a
consensus-based recommendation cannot be issued)
 Current practice (a consensus-based recommendation cannot be issued if a service is not
currently widely used)
 Why, if warranted, a more costly service is being recommended over a less costly one
The AAOS employs additional rules to combat the bias that may affect such recommendations.
The rationale for the recommendation cannot contain references to studies that were not included
in the systematic reviews that underpin a guideline. Excluded articles are, in effect, not evidence,
and they may not be cited. Also, the final recommendation must use the language shown in Table
10. The rationale cannot contain the language “we recommend,” “we suggest,” or “the
practitioner might” inasmuch as this wording could be confused with the evidence-based
recommendations in a guideline. In addition, the rationale must address apparent discrepancies in
logic with other recommendations in the guideline. For example, if a guideline does not come to
a recommendation in some instances but, in the instance in question, the work group has issued a
consensus-based recommendation, the rationale must explain the reason for this difference.
One consequence of these restrictions is that the AAOS does not typically recommend new
medical devices, drugs, or procedures. These procedures are usually supported by little research,
and the AAOS is reluctant to make recommendations that could have a national impact based on
small amounts of data.
When it is not possible to issue a recommendation (i.e. when the recommendation reads that “we
are unable to recommend for or against”) the explanation for why a recommendation cannot be
given cannot contain an implied recommendation. For example, in the case of a new device,
drug, or procedure, the work group may not write a recommendation similar to “Although the
treatment appears to be promising, there is currently insufficient evidence to recommend for or
against its use.” The italicized phrase implies that the treatment is effective, whereas not being

able to recommend “for or against” something implies that effectiveness is currently
indeterminate.
More details of our rules for making opinion based recommendation can be found in Appendix
VI
VOTING ON THE RECOMMENDATIONS

The recommendations and their strength were voted on using a structured voting technique
known as the nominal group technique.28 We present details of this technique in Appendix VII.
Voting on guideline recommendations is conducted using a secret ballot and work group
members are blinded to the responses of other members. If disagreement between work group
members is significant, there is further discussion to see whether the disagreement(s) can be
resolved. Up to three rounds of voting are held to attempt to resolve disagreements. If
disagreements are not resolved following three voting rounds, no recommendation is adopted.
Lack of agreement is a reason that the grade of some recommendations can be labeled
“Inconclusive.”
Formal votes on all recommendations that are evidence-based or that read “we are unable to
recommend for or against” are only on the recommendations. The rationales require only
approval of the work group chair and the methodologists unless the recommendation is
consensus-based. Both the recommendation and the rationale of a consensus-based
recommendation are the subject of formal votes.
OUTCOMES CONSIDERED
In considering the outcomes discussed in this guideline, it is important to distinguish between
patient-oriented and surrogate outcomes. Patient-oriented outcomes measure how a patient feels,
functions, or survives.29 A patient-oriented outcome “tells clinicians, directly and without the
need for extrapolation, that a diagnostic, therapeutic or preventive procedure helps patients live
longer or live better.”30 Patient-oriented outcomes include pain relief, death, and fractures.
Surrogate outcomes are laboratory measurements or physical signs used as substitutes for
patient-oriented outcomes. Surrogate outcomes include outcomes like blood cholesterol levels,
laboratory and imaging results, and bone mineral densities.
Surrogate outcomes are problematic. An intervention that improves a surrogate outcome does not
necessarily improve a patient-oriented outcome. The opposite can be true. Using a surrogate
outcome as a study endpoint can make a harmful treatment look beneficial. For example,
although the surrogate outcome cardiac sinus rhythm improves when quinidine is given after
conversion, mortality is tripled. Similarly, sodium fluoride increases bone mineral density, but it
also increases the rate of non-vertebral fractures.30, 31 This leads to an important (and often
overlooked) aspect about surrogate outcomes. To be useful, a surrogate outcome must not only
correlate with the patient-oriented outcome of interest, but also the surrogate must predict
(capture) the effects of an intervention on that outcome.29, 31, 32 Additionally, many surrogates
may correlate with an outcome, but few predict the effects of an intervention. For these reasons,
the AAOS rarely uses surrogate outcomes as endpoints in its clinical practice guidelines. We
make an exception, in this guideline, for bacteremia associated with a dental procedure because
there is little reliable evidence predicting the effects of bacteremia associated with a dental
procedure on orthopaedic implant infections.

STATISTICAL METHODS
When possible, we recalculate the results reported in individual studies and compile them to
answer the recommendations. The statistical analysis is conducted using STATA 10.033. STATA
was used to determine the magnitude, direction, and/or 95% confidence intervals of the treatment
effect. For data reported as means (and associated measures of dispersion) the mean difference
between groups and the 95% confidence interval was calculated and a two-tailed t-test of
independent groups was used to determine statistical significance. When published studies report
measures of dispersion other than the standard deviation the value was estimated to facilitate
calculation of the treatment effect. In studies that report standard errors or confidence intervals
the standard deviation was back-calculated. In studies that only report the median, range, and/or
size of the trial, we estimated the means and variances according to a published method.34 In
some circumstances statistical testing was conducted by the authors and measures of dispersion
were not reported. In the absence of measures of dispersion, the results of the statistical analyses
conducted by the authors (i.e. the p-value) are considered as evidence. For proportions, we report
the ratio of events along with the percentage. P-values < 0.05 were considered statistically
significant.
We performed network meta-analyses (also known as a mixed treatment comparisons analyses)

to ascertain the comparative effectiveness of strategies for preventing bacteremia among patients
undergoing dental extraction. All of the trials entered into our analyses were randomized
controlled trials (most, but not all, were of “Moderate” quality; additional details on their quality
are presented in the sections of this guideline that present our results of the appraisal of these
studies).
Analyses were performed as described by Lu and Ades35 using Winbugs v 1.4.3. This method
preserves the randomization of the original trials. The Markov chains in our model were said to
have converged if plots of the Gelman-Rubin statistics indicated that widths of pooled runs and
individual runs stabilized around the same value and their ratio was approximately one.36 In
general, we performed 100,000 iterations, the first 50,000 of which were discarded as “burn in”
iterations for each of the network models we describe. We specified vague priors for the trial
baselines and the basic parameters (normal distribution with mean 0 and variance 10,000) and
for the random effects standard deviation (uniform distribution: U(0,2)). We use p <0.05 to
define statistical significance.
To assess the adequacy of our models, we checked their overall fit by comparing the posterior
mean deviance to the number of data points in any given model. These two figures are
approximately equal for models that fit the data well. We also checked the statistical consistency
of the models using a “back-calculation” method for networks with direct evidence from multi-
arm trials.37 This method requires point estimates and dispersions of the trial data being entered
into the network meta-analysis. When there were two or more trials comparing two of the same
treatments, we obtained these latter two quantities from traditional random effects meta-analytic
models computed according to the method of DerSimonian and Laird.38 All traditional meta-
analyses were performed using STATA.
We performed separate network meta-analyses for antibiotic prophylaxis and for non-antibiotic
prophylaxis (e.g., antiseptic rinses) because the analysis combining both types of prophylaxis
resulted in a statistically inconsistent model.

PEER REVIEW
A draft of the present guideline was peer reviewed. Peer review was performed using a
structured peer review form (see Appendix VIII). This form requires all peer reviewers to declare
their conflicts of interest.
To determine who would serve as peer reviewers, the work group nominated external specialty
societies before work on the guideline began. By having work groups specify organizations for
review (as opposed to individuals), we are attempting to prevent overly favorable reviews that
could arise should work group members choose reviewers whom they had personal or
professional relationships. We also blind peer reviewers to the identities of the work group
members when they peer review the draft.
The outside specialty societies were nominated at the beginning of the process and solicited for
names of peer reviewers approximately six weeks before the final recommendation meeting for a
guideline. The physician members of the AAOS Guidelines Oversight Committee and the
Evidence Based Practice Committee review all draft AAOS clinical practice guidelines. In
addition, the ADA Council on Scientific Affairs will review the guideline.
On occasion, some specialty societies (both orthopaedic and non-orthopaedic) ask their
evidence-based practice (EBP) committee to provide peer review of our guidelines. The specialty
society is responsible for compiling this type of review into one document before it is returned to
us. We ask that the Chairpersons of these external EBP committees declare their conflicts of
interest and manage the conflicts of interest of their committee members. Some specialty
societies ask to post the guideline on their website for review by all of their interested members.
Again, the AAOS asks that these reviews be collated into a single response by the specialty
society, and that the person responsible for submitting this document to the AAOS disclose his or
her financial conflicts of interest. We also ask that this posting be to the “members” only portion
of the specialty societies’ website because our drafted document represents a “work in progress”
and is subject to change as a direct result of the review process. In addition, the draft has not
been formally approved by the AAOS Board of Directors or the ADA Board of Trustees. This is
not an attempt to restrict input on the draft. Nor do we consider it as a method to imply that
outside specialty societies who provide review of the document necessarily agree with the stated
recommendations. Hence, the reason all peer review comments and our responses are made
publicly available.
AAOS and ADA staff drafted initial responses to comments about methodology. These
responses were then reviewed by the work group co-chairs , who also respond to questions
concerning clinical practice and techniques. All changes to a recommendation as a result of peer
review input were voted on and accepted by a majority of the work group members via
teleconference. All changes to any guideline recommendation are based on the evidence in the
guideline recommendations. Final changes to the guideline are incorporated, detailed in a
summary sheet and forwarded with the document through the rest of the review and approval
process.
The AAOS and ADA believe that it is important for guideline developers to demonstrate that
they are responsive to peer review. Accordingly, after the AAOS Board of Directors approves a
guideline, the AAOS posts all peer reviewer comments on its website (see

http://www.aaos.org/research/guidelines/guide.asp to access these documents) with a point-by-
U U
point description of how the AAOS responded to each non-editorial comment made by each
reviewer. Reviewers who wish to remain anonymous can notify the AAOS, and their names will
be redacted; their comments, our responses and their conflicts of interest will however still be
posted for review.
Forty-seven outside organizations were solicited to provide peer reviewers for this document.
The draft of this guideline was sent to seventeen review organizations who responded to the
solicitation and a total of twenty-three peer reviewers received the document not including the
AAOS Evidence-based Practice Committee and Guidelines Oversight Committee members.
Eighteen of these reviewers returned comments (see Appendix IX). The disposition of all non-
editorial peer review comments was documented and accompanied this guideline through the
public commentary and the AAOS guideline approval process.
PUBLIC COMMENTARY
After modifying the draft in response to peer review, the guideline was sent for a thirty day
period of “Public Commentary.” Public Commentators are blinded to the identities of the work
group members. Commentators consist of members of the AAOS Board of Directors (BOD),
members of the Council on Research and Quality (CORQ), members of the Board of Councilors
(BOC), and members of the Board of Specialty Societies (BOS). AAOS guidelines are
automatically forwarded to the AAOS BOD and CORQ for commentary. Members of the BOC
and BOS are solicited for interest. If they ask to see the document, it is forwarded to them. In
addition, the guideline will be forwarded to the ADA Board of Trustees, Council on Dental
Practice, Council on Access, Prevention and Interprofessional Relations, Council on Dental
Benefit Programs, and Council on Dental Education and Licensure for commentary.
The draft guideline is, if warranted, modified in response to public commentary by the AAOS
Clinical Practice Guidelines Unit, the ADA Division of Science, and the work group members. If
changes are made as a result of public comment, these changes are summarized, and those who
provided commentary are notified that their input resulted in a change in the guideline. Changes
as a result of public commentary are based on evidence in the guideline recommendations. All
changes are detailed in a summary sheet that accompanies the document through the approval
process.
Over one hundred commentators have had the opportunity to provide input into this guideline.
Of these, fifty-eight members received the document and five returned comments (see Appendix
IX).
THE AAOS GUIDELINE APPROVAL PROCESS

This final guideline draft was approved by the AAOS Evidence Based Practice Committee, the
AAOS Guidelines Oversight Committee, the AAOS Council on Research and Quality, the ADA
Council on Scientific Affairs, the AAOS Board of Directors, and the ADA Board of Trustees.
Descriptions of these bodies are provided in Appendix X. These reviewing bodies do not have
the option to modify the draft guideline during the approval process. They can only vote to
approve it or reject it. Accordingly, no changes were made to this guideline during the approval
process.

REVISION PLANS
This guideline represents a cross-sectional view of current treatment and may become outdated
as new evidence becomes available. This guideline will be revised in accordance with new
evidence, changing practice, rapidly emerging treatment options, and new technology.
Accordingly, this guideline will be updated or withdrawn in five years in accordance with the
standards of the National Guideline Clearinghouse.
GUIDELINE DISSEMINATION PLANS

The primary purpose of the present document is to provide interested readers with full
documentation about not only our recommendations, but also about how we arrived at those
recommendations. This document is also posted on the AAOS website at
http://www.aaos.org/research/guidelines/guide.asp.
Guidelines are first announced by a press release and then published on the AAOS’s and the
ADA’s website. Guideline summaries are published in the Journal of the American Academy of
Orthopaedic Surgeons, Journal of the American Dental Association, AAOS Now and ADA News.
In addition, guidelines are disseminated at the AAOS Annual Meeting in various venues such as
on Academy Row and at Committee Scientific Exhibits.
Selected guidelines are disseminated by webinar, an Online Module for the Orthopaedic
Knowledge Online website, Radio Media Tours, Media Briefings, and by distributing them at
relevant Continuing Medical Education (CME) courses and at the AAOS Resource Center.
Other dissemination efforts outside of the AAOS and ADA include submitting the guideline to
the National Guideline Clearinghouse and distributing the guideline at other medical specialty
societies’ meetings.

OVERVIEW OF THE EVIDENCE
As illustrated in Figure 1, there is varying quality of evidence that explains the proposed
association between dental procedures and orthopaedic implant infection. Only one study of
direct evidence of moderate strength (represented in Figure 1 below, by the arching arrow) was
considered for this guideline. The results of this study show that dental procedures are not risk
factors for subsequent implant infection and furthermore that antibiotic prophylaxis does not
reduce the risk of subsequent infection.39 However, multiple high strength studies of indirect
evidence link oral procedures to bacteremia, a surrogate measure of risk of orthopaedic implant
infection. Furthermore, multiple moderate strength studies of indirect evidence suggest that
prophylaxis decreases the incidence of post dental procedure bacteremia. No studies exist that
explain the microbiological relationship between bacteremia and orthopaedic implant infection.
Figure 1 Overview of the Evidence
Prophylaxis
Mouth Blood Implant

Infection
High Strength
Moderate Strength
Low Strength
No Evidence
DIRECT EVIDENCE
FINDINGS
The results of one study provide direct evidence for the association between dental
procedures and antibiotic prophylaxis on prosthetic hip and knee infection. This single-
center, case-control study prospectively enrolled patients between 2001and 2006. 339 case
patients were diagnosed with a prosthetic hip or knee infection. 339 control patients were
hospitalized on an orthopedic service without a prosthetic hip or knee infection.
Characteristics of case and control patients were compared, risk factors for prosthetic hip
or knee infection were analyzed and multivariate logistic regression was performed to
assess the association between variables and odds of infection. The model included
covariates of sex, joint age, dental propensity score, body mass index >40, procedure time
>4 h, immunocompromised host, American Society of Anesthesiologists score, wound
healing complications, prior arthroplasty or surgery on the index joint, use of surgical
antibiotic prophylaxis, postoperative urinary tract infection, and distant organ infection.
The results from this model show that low and high-risk dental procedures (see Table 11)

performed within 6 months and 2 years of the hospital admission date were not
significantly associated with increased risk of prosthetic hip or knee infection compared
with no dental procedure (see Table 12 for a summary of the results of the logistic
regression model). The model also assessed the association between antibiotic prophylaxis
and prosthetic joint infection. Low and high-risk dental procedures with antibiotic
prophylaxis were compared with the same procedures without prophylaxis. No significant
associations were found (see
Table 13).
Table 11 High and Low Risk Dental Procedures Defined by Berbari, et al.
High Risk Dental Procedures Low Risk Dental Procedures
Dental abscess therapy Dental fillings
Dental extraction Endodontic treatment
Dental filing Fluoride treatment
Dental hygiene Restorative dentistry
Periodontal treatment
Mouth surgery
based on the 1997 version of the American Heart Association Guideline on
Infective Endocarditis
QUALITY AND APPLICABILITY
Only one study of moderate quality and applicability exists that provides direct evidence for an
association between dental procedures and prosthetic hip and knee infection. Details of our
appraisal of this study are provided in Table 69 of Appendix XII.
RESULTS
Table 12 Dental procedures performed and risk of prosthetic hip or knee infection at 6
months and 2 years
Odds Ratio (95% Confidence Interval)
Variable 6 months P 2 years P
Low-risk dental procedure
Low-risk dental procedure 1.1 (0.6-2.1) 0.77 0.6 (0.4-1.1) 0.11
without antibiotic
prophylaxis
Low-risk dental procedure 0.7 (0.3-1.5) 0.33 0.8 (0.5-1.2) 0.29
with antibiotic prophylaxis
High-risk dental procedure
High-risk dental procedure 0.8 (0.4-1.7) 0.6 0.8 (0.4-1.6) 0.56
without antibiotic
prophylaxis
High-risk dental procedure 0.5 (0.3-0.9) 0.01 0.7 (0.5-1.1) 0.14
with antibiotic prophylaxis

Table 13 Antibiotic prophylaxis and risk of prosthetic hip or knee infection at 6 months
and 2 years
Odds Ratio (95% Confidence Interval)
Variable 6 Months 2 Years
Antibiotic Prophylaxis
Low-risk procedure 0.7 (0.3-1.5) 1.2 (0.7-2.2)
High-risk procedure 0.7 (0.3-1.4) 0.9 (0.5-1.6)

INDIRECT EVIDENCE: DENTAL PROCEDURES AND BACTEREMIA
FINDINGS
Multiple studies of high quality regarding dental procedures with bacteremia as the outcome are
considered for this guideline. Rates of bacteremia after dental procedures varied significantly by
and within procedure group. Rates are reported as either incidence or prevalence. We focused
primarily on the incidence data because these studies reported new cases of bacteremia as a
result of the dental procedure. Studies that reported prevalence did not take the necessary
measures to ensure that the study population was free of bacteremia before undergoing their
respective dental procedures. Due to the heterogeneity of bacteremia rates within procedure
group we were unable to calculate an accurate mean value. Therefore the rates of bacteremia are
presented in box plots in Figure 2 & Figure 4. Median incidence rates range from approximately
5% for chewing to upwards of 65% for simple tooth extraction and gingivectomy. Prevalence
rates are comparable. Rates of bacteremia were represented by a single study in some cases (see
Figure 3 & Figure 5 for details). Individual study details can be found in
Table 63 and Table 64 in Appendix XI.

Refer to Table 97 to Table 113 in Appendix XII.

RESULTS
Figure 2 Incidence of bacteremia by procedure group

Figure 3 Incidence of bacteremia in single study groups

Figure 4 Prevalence of bacteremia by group

Figure 5 Prevalence of bacteremia in single study groups

INDIRECT EVIDENCE: RISK FACTORS FOR DENTAL PROCEDURE
RELATED BACTEREMIA
FINDINGS
While the quality of the evidence is low, several prognostic studies have addressed a multitude of
patient characteristics as potential risk factors for developing bacteremia from dental procedures.
These low strength studies report on oral health indicators and general patient characteristics
such as age, gender, etc. The results vary across and within procedure groups. Evidence is often
contradictory. See Table 14 for a summary of significant findings and Table 15 - Table 23 for
details.

Refer to Table 88 - Table 96 in Appendix XII.

RESULTS
Table 14 Summary of Risk Factor Significance (Proportion of studies that reported significant results)
Risk Factor Brushing Chewing Dental Inter- Intubation Oral Periodontic Restorative Tooth
Prophylaxis dental Surgery Extraction
Cleaning
Patient Results (% Significant, n/N)
Characteristics
Age 50%, 1/2 33%, 1/3 50%, 1/2 0%, 0/1 0%, 0/2 0%, 0/1 0%, 0/1 33%, 1/3
BMI 0%, 0/1
Cirrhosis 100%, 1/1
Diabetes 0%, 0/1
Gender 0%, 0/2 0%, 0/3 0%, 0/2 0%, 0/1 0%, 0/2 0%, 0/1 0%, 0/3
Inflammatory 100%, 100%, 2/2
Disease 1/1
Mixed 0%, 0/1
Dentition
Race 0%, 0/1
Smoking 0%, 0/2 0%, 0/1 0%, 0/1
Status
Procedure
# Teeth 0%, 0/1 100%, 4/4
Extracted
Anaesthesia 0%, 0/1
Anaesthetic 100%, 1/1
Modality
Anaesthetic 0%, 0/1
Technique
Bleeding 0%, 0/1 50%, 1/2 0%, 0/1 100%, 50%, 1/2 50%, 1/2
1/1
Bleeding 100%, 1/1 0%, 0/1
Type
Blood Loss 0%, 0/1 100%, 1/1

Cleaning
Procedure 0%, 0/1 0%, 0/1 100%,
Time 1/1
Oral Health
# Teeth 0%, 0/1 0%, 0/1
Present
Abscess 0%, 0/1 0%, 0/2
Apical 0%, 0/1 0%, 0/1
Lucency
Calculus 100%, 1/1 0%, 1/1
Index/Score
Caries 0%, 0/1 0%, 0/1 0%, 0/1
Caries Depth 0%, 0/1 0%, 0/1 0%, 0/1
Clinical 0%, 0/1
Attachment
Loss
Gingival 25%, 1/4 100%, 1/1 0%, 0/1 50%, 100%, 1/1 67%, 2/3
Index/Score 1/2
Gingival Size 0%, 0/1
Gingivitis 0%, 0/1 0%, 0/1 0%, 0/1
Infected 100%,
Tooth 1/1
Odontogenic 0%, 0/1
Disease
Oral Health 0%, 0/1 0%, 0/1 50%, 1/2
Status
Periodontal 0%, 0/1 0%, 0/1
Diagnosis
Periodontitis 0%, 0/1 0%, 0/1 100%, 1/1 0%, 0/1 50%, 1/2 0%, 0/1
Plaque 67%, 2/3 50%, 1/2 0%, 0/1 0%, 0/1 0%, 0/3
Index/Score

Cleaning
Probing 0%, 0/2 0%, 0/1 0%, 0/1 33%, 1/3
Depth
Probing 0%, 0/1 100%, 1/1 0%, 0/1
Depth Mean
Radiolucency 0%, 0/1
Recession 0%, 0/1
Suppuration 0%, 0/1
Swelling 0%, 0/1
Tooth 0%, 0/1 0%, 0/1
Mobility

Table 15 Risk Factors for Brushing Bacteremia
Author Strength N Statistical Test Outcome Risk Factor Results
Ashare Low 48 ANOVA Bacteremia Cirrhosis p<0.01 for all
2009 followed by (Bacterial Load @ time points
Bonferroni 30s, 5m, 15m)
Ashare Low 48 unknown Bacteremia Age NS for all
2009 (Bacterial Load @ time points
30s, 5m, 15m)
Lockhart Low 98 logistic Bacteremia Age OR 1.06
2009 regression (Infective p=.017
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia BMI OR 0.99
Endocarditis
related bacteria)
Ashare Low 48 unknown Bacteremia Gender NS for all
2009 (Bacterial Load @ time points
30s, 5m, 15m)
Lockhart Low 98 logistic Bacteremia Sex (risk OR 1.09
2009 regression (Infective level=female) p=.866
Endocarditis
related bacteria)
Ashare Low 48 Linear Bacteremia Plaque Index p<0.01 @ 30s
2009 regression (Bacterial Load @ & 5m, NS @
30s, 5m, 15m) 15m
Bhanji Low 50 logistic Bacteremia Plaque Score OR 1.05,
2002 regression p=0.44
Lockhart Low 98 logistic Bacteremia Mean plaque OR 2.53
2009 regression (Infective score p=.010
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia Plaque score OR 3.78
2009 regression (Infective ≥2 p=.008
Endocarditis
related bacteria)
Ashare Low 48 Linear Bacteremia Gingival NS for all
2009 regression (Bacterial Load @ Index time points
30s, 5m, 15m)
Bhanji Low 50 chi square Bacteremia Gingival p=0.96
2002 Score
Lockhart Low 98 logistic Bacteremia Mean gingival OR 1.62
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia Gingival OR 1.61
2009 regression (Infective score ≥ 2 p=.335
Endocarditis
related bacteria)

Silver Low 96 Critical ratio test Bacteremia Gingival p<.01
1977 Index
Forner Low 20 Fishers exact test Bacteremia Gingivitis NS
2006
Forner Low 20 Fishers exact test Bacteremia Periodontitis NS
2006
Lockhart Low 98 logistic Bacteremia Mean calculus OR 1.77
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia Calculus OR 4.43
2009 regression (Infective score ≥ 2 p=.004
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia Bleeding with OR 0.89
2009 regression (Infective toothbrushing p=.810
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia Bleeding type OR 7.96
2009 regression (Infective with p=.015
Endocarditis toothbrushing
related bacteria)
Lockhart Low 98 logistic Bacteremia Mean probing OR 1.02
2009 regression (Infective depth p=.918
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia Tooth OR 1.93
2009 regression (Infective mobility score p=.200
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia Dental caries OR 4.40
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia Depth of OR 0.43
2009 regression (Infective dental caries p=.155
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia Apical OR 2.37
2009 regression (Infective lucency p=.086
Endocarditis
related bacteria)
Lockhart Low 98 logistic Bacteremia Apical OR 0.87
2009 regression (Infective lucency size p=.647
Endocarditis (mm)
related bacteria)

Table 16 Risk Factors for Chewing Bacteremia
Forner Very Low 20 Fisher's exact test Bacteremia Periodontitis NS
2006
Forner Very Low 20 Fisher's exact test Bacteremia Gingivitis NS
2006
Table 17 Risk Factors for Dental Prophylaxis Bacteremia

Cherry Low 60 Logistic Bacteremia Age OR 1.4 p=.05
2007 regression
De Leo Low 39 Chi square Bacteremia Age 6.31, NS
1974
Forner Low 20 Spearman's Bacteremia Age NS
2006 correlation (magnitude)
coefficients
Cherry Low 60 Logistic Bacteremia Gender NS
2007 regression
De Leo Low 39 Chi square Bacteremia Sex NS
1974
Forner Low 20 Spearman's Bacteremia Gender NS
coefficients
Cherry Low 60 Logistic Bacteremia Smoking NS
2007 regression status
Forner Low 20 Spearman's Bacteremia Smoking NS
coefficients
Cherry Low 60 Logistic Bacteremia Plaque Index NS
2007 regression
Forner Low 20 Spearman's Bacteremia Plaque Index 0.41 p=.0117
coefficients
Cherry Low 60 Logistic Bacteremia Modified NS
2007 regression papilla,
margin,
attached
gingiva index
Cherry Low 60 Logistic Bacteremia Probing depth NS
2007 regression
Cherry Low 60 Logistic Bacteremia Recession NS
2007 regression
Cherry Low 60 Logistic Bacteremia Bleeding on NS
2007 regression scaling
Forner Low 20 Fishers exact test Bacteremia Periodontitis p<.001
2006

Forner Low 20 Spearman's Bacteremia Periodontal NS
2006 correlation (magnitude) diagnosis
coefficients
Forner Low 20 Fishers exact test Bacteremia Gingivitis NS
2006
Forner Low 20 Spearman's Bacteremia Gingival 0.53 p<.0001
2006 correlation (magnitude) Index
coefficients
Forner Low 20 Spearman's Bacteremia Bleeding on 0.45 p=.0089
2006 correlation (magnitude) probing
coefficients
Forner Low 20 Spearman's Bacteremia Probing NS
2006 correlation (magnitude) pocket depth
coefficients >5
Forner Low 20 Spearman's Bacteremia Pocket sum NS
2006 correlation (magnitude) score
coefficients
Forner Low 20 Spearman's Bacteremia Scaling time* NS
coefficients
Trivedi Low 40 Chi square Bacteremia Diabetes 4.5 p>0.5
1984
*Procedure related risk factor
Table 18 Risk Factors for Inter-dental Cleaning Bacteremia

Crasta Low 60 Spearman's Bacteremia Periodontitis 0.17 p=.2
2009 correlation
coefficients
Crasta Low 60 Spearman's Bacteremia Age 0.18 p=.2
2009 correlation
coefficients
Linberger Low 21 Chi square Bacteremia Age 0.81 p<.04
1973
Crasta Low 60 Spearman's Bacteremia Gender −0.08 p=.5
2009 correlation
coefficients
Linberger Low 21 Exact method of Bacteremia Sex 1.97, NS
1973 binomial dist.
Crasta Low 60 Spearman's Bacteremia Smoking −0.04 p=.7
2009 correlation status
coefficients
Crasta Low 60 Spearman's Bacteremia Time spent −0.04 p=.8
2009 correlation flossing*
coefficients
Crasta Low 60 Spearman's Bacteremia Gingival 0.22 p=.09
2009 correlation Index
coefficients

Crasta Low 60 Spearman's Bacteremia Plaque Index 0.07 p=.6
2009 correlation
coefficients
Crasta Low 60 Spearman's Bacteremia % of sites 0.17 p=.2
2009 correlation bleeding on
coefficients flossing
Crasta Low 60 Spearman's Bacteremia # sites 0.17 p=.2
coefficients flossing
Crasta Low 60 Spearman's Bacteremia % of sites 0.16 p=.2
coefficients probing
Crasta Low 60 Spearman's Bacteremia Pocket depth 0.09 p=.5
2009 correlation
coefficients
Crasta Low 60 Spearman's Bacteremia Clinical 0.06 p=.6
2009 correlation attachment
coefficients loss
Crasta Low 60 Spearman's Bacteremia Self-reported −0.12 p=.4
2009 correlation daily flossing
coefficients
Table 19 Risk Factors for Intubation Bacteremia

Valdes Low 110 Logistic Bacteremia Age NS
2008 regression
Valdes Low 110 Logistic Bacteremia Sex NS
2008 regression
Valdes Low 110 Logistic Bacteremia Oral health NS
Table 20 Risk Factors for Oral Surgery Bacteremia

Enabulele Low 170 chi-square Bacteremia Inflammatory 0.004 p=.05
2008 disease
Enabulele Low 170 chi-square Bacteremia Sex NS
2008
Tomas Low 100 not reported Bacteremia Gender NS
2008
Roberts Low 154 chi-square Bacteremia Abscess 1.878
1998 p=.1706
Roberts Low 154 Pearson Bacteremia Age 0.29
1998 correlation
coefficient
Tomas Low 100 not reported Bacteremia Age NS
2008

Roberts Low 154 Scheffe's Bacteremia Plaque Index p=.47
1998 multiple
comparison
Roberts Low 154 Scheffe's Bacteremia Gingival p<.03
1998 multiple Index
comparison
Takai Low 237 chi-square Bacteremia Gingival NS
2005 Index
Roberts Low 154 Scheffe's Bacteremia Bleeding p<.04
1998 multiple Index
comparison
Takai Low 237 chi-square Bacteremia Oral hygiene NS
2005 index
simplified
Takai Low 237 chi-square Bacteremia # teeth present NS
2005
Takai Low 237 chi-square Bacteremia Blood loss NS
2005
Takai Low 237 chi-square Bacteremia Duration of p<.05
2005 procedure*
Takai Low 237 chi-square Bacteremia # teeth NS
2005 extracted*
Takai Low 237 chi-square Bacteremia Method of NS
2005 procedure*
Takai Low 237 chi-square Bacteremia Infection in p<.01
2005 extracted tooth
(periodontitis,
periapical
infection, and
pericoronitis)
Takai Low 237 chi-square Bacteremia Anaesthesia NS
2005 for procedure*
Table 21 Risk Factors for Periodontic Bacteremia

Daly Low 30 chi-square Bacteremia Periodontitis p=.9
1997 severity
Daly Low 40 logistic Bacteremia Periodontitis OR 5.993
2001 regression CI=1.081-
33.215
Daly Low 30 t-test Bacteremia Bleeding on p=.3
1997 probing
Daly Low 40 logistic Bacteremia Bleeding on OR 1.025
2001 regression probing CI=1.004-
1.047

Daly Low 40 logistic Bacteremia Age OR 1.008
2001 regression CI=.960-
1.058
Daly Low 40 logistic Bacteremia Sex NS
2001 regression
Daly Low 40 logistic Bacteremia Smoking NS
Daly Low 40 logistic Bacteremia # of teeth OR 1.0
1.185
Daly Low 40 logistic Bacteremia Total probing OR 1.006
2001 regression depth CI=.999-
1.013
Daly Low 40 logistic Bacteremia Plaque index OR 3.154
16.514
Daly Low 40 logistic Bacteremia Mean probing OR 1.444
2001 regression depth per CI=.1.055-
tooth 1.977
Table 22 Risk Factors for Restorative Bacteremia

Brennan Very Low 51 chi-square or Bacteremia Age p=.06
2007 fisher's exact
Brennan Very Low 51 chi-square or Bacteremia Sex NS
2007 fisher's exact
Brennan Very Low 51 chi-square or Bacteremia Race NS
2007 fisher's exact
Brennan Very Low 51 chi-square or Bacteremia Gingival p=.01
2007 fisher's exact Score (0-3)
Brennan Very Low 51 chi-square or Bacteremia Gingival Size NS
2007 fisher's exact (0-3)
Brennan Very Low 51 chi-square or Bacteremia Periodontal NS
2007 fisher's exact disease with
probing
>3mm
Brennan Very Low 51 chi-square or Bacteremia Mixed p=.08
2007 fisher's exact Dentition
Brennan Very Low 51 chi-square or Bacteremia Caries Present NS
2007 fisher's exact
Brennan Very Low 51 chi-square or Bacteremia Depth of NS
2007 fisher's exact caries (0-3)
Brennan Very Low 51 chi-square or Bacteremia Periapical NS
2007 fisher's exact radiolucency
Brennan Very Low 51 chi-square or Bacteremia Size NS
2007 fisher's exact radiolucency
(mm)

Brennan Very Low 51 chi-square or Bacteremia Swelling NS
2007 fisher's exact
Brennan Very Low 51 chi-square or Bacteremia Suppuration NS
2007 fisher's exact
Table 23 Risk Factors for Extraction Bacteremia

Barbosa Low 210 logistic Bacteremia 30s Oral health OR 3.704
2010 regression status (1.929-
(univariate) 7.109)
Barbosa Low 210 logistic Bacteremia 15m Oral health OR 2.047
2010 regression status (1.138-
(univariate) 3.683)
Wahlmann Low 59 logistic Bacteremia Oral Hygiene NS
1999 regression
Wahlmann Low 59 logistic Bacteremia Periodontal NS
Barbosa Low 210 logistic Bacteremia 30s Local anesthetic OR 0.143
2010 regression technique* (0.063-
(univariate) 0.323), OR
0.119
(0.046-
0.309)
Barbosa Low 210 logistic Bacteremia 15m Local anesthetic OR 0.179
0.186
(0.076-
0.455)
Barbosa Low 210 logistic Bacteremia 60m Local anesthetic OR 0.118
0.251
(0.055-
1.135)
Barbosa Low 210 logistic Bacteremia 30s Anesthetic OR 7.431
2010 regression modality* (3.453-
(univariate) 15.990)
Barbosa Low 210 logistic Bacteremia 15m Anesthetic OR 5.518
Barbosa Low 210 logistic Bacteremia 30s Anesthetic OR 5.040
(multivariate) 12.283)

Barbosa Low 210 logistic Bacteremia 15m # of OR 1.126
2010 regression extractions* (1.046-
(univariate) 1.212)
Barbosa Low 210 logistic Bacteremia 60m # of OR 1.128
2010 regression extractions* (1.042-
(univariate) 1.222)
Coulter Low 58 Spearman's Bacteremia # of teeth r=0.08
1990 correlation extracted*
coefficient
Okabe 1995 Low 183 Mann-Whitney Bacteremia # of 4367.5
extractions* p<.0001
Wahlmann Low 59 logistic Bacteremia # of Significant
1999 regression extractions* for Control
grp
Coulter Low 58 chi-square Bacteremia Plaque Index NS
1990
Lockhart Low 96 logistic Bacteremia Mean plaque OR 0.74
2009 regression score p=.236
Lockhart Low 96 logistic Bacteremia Plaque score ≥ 2 OR 0.90
2009 regression p=.811
Roberts Low 154 Scheffe's Bacteremia Plaque Index p=.47
1998 multiple
comparison
Coulter Low 58 chi-square Bacteremia Gingival Index NS
1990
Lockhart Low 96 logistic Bacteremia Mean gingival OR 0.71
Lockhart Low 96 logistic Bacteremia Gingival score OR 0.76
2009 regression ≥2 p=.518
Roberts Low 154 Scheffe's Bacteremia Gingival Index p<.03
1998 multiple
comparison
Coulter Low 58 Fisher's Bacteremia Abscess p=0.2088
1990
Roberts Low 154 chi-square Bacteremia Abscess 1.878
1998 p=.1706
Enabulele Low 170 chi-square Bacteremia Inflammatory 0.004 p=.05
2008 disease
Okabe 1995 Low 183 Fisher's Bacteremia Inflammatory p<.0005
disease
Enabulele Low 170 chi-square Bacteremia Sex NS
2008

Lockhart Low 96 logistic Bacteremia Sex (risk OR 1.64
2009 regression level=female) p=.241
Okabe 1995 Low 183 Fisher's Bacteremia Sex 0.624, NS
Lockhart Low 70 chi-square or Bacteremia Surgery Time < p=.04
1996 Fisher's exact 3m*
Lockhart Low 70 chi-square or Bacteremia Surgery Time > p=.04
1996 Fisher's exact 6m*
Okabe 1995 Low 183 Mann-Whitney Bacteremia Duration of 4050 p<.05
procedure*
Wahlmann Low 59 logistic Bacteremia Duration of NS
1999 regression procedure*
Lockhart Low 70 chi-square or Bacteremia Odontogenic NS
1996 Fisher's exact disease severity
Lockhart Low 96 logistic Bacteremia Age OR 1.03
Okabe 1995 Low 183 Mann-Whitney Bacteremia Age 4517.5
p<.0005
Roberts Low 154 Pearson Bacteremia Age 0.29
1998 correlation
coefficient
Lockhart Low 96 logistic Bacteremia BMI OR 0.99
Lockhart Low 96 logistic Bacteremia Mean calculus OR 0.93
Lockhart Low 96 logistic Bacteremia Calculus score OR 0.82
2009 regression ≥2 p=.715
Lockhart Low 96 logistic Bacteremia Bleeding with NA
2009 regression toothbrushing
Lockhart Low 96 logistic Bacteremia Bleeding type NA
2009 regression with
toothbrushing
Okabe 1995 Low 183 Mann-Whitney Bacteremia Blood loss (ml) 3997.5 p<.05
Roberts Low 154 Scheffe's Bacteremia Bleeding Index p<.04
1998 multiple
comparison
Lockhart Low 96 logistic Bacteremia Mean probing OR 0.95
2009 regression depth p=.735
Lockhart Low 96 logistic Bacteremia Tooth mobility OR 1.01
Lockhart Low 96 logistic Bacteremia Dental caries OR 1.66
Lockhart Low 96 logistic Bacteremia Depth of dental OR 0.21
2009 regression caries p=.156
Lockhart Low 96 logistic Bacteremia Apical lucency OR 0.86
Lockhart Low 96 logistic Bacteremia Apical lucency OR 1.00
2009 regression size (mm) p=.995

INDIRECT EVIDENCE: PROPHYLAXIS FOR DENTAL PROCEDURE
RELATED BACTEREMIA
FINDINGS
We recognize the diversity of opinion concerning the clinical importance of bacteremia as a
surrogate outcome for orthopaedic implant infection and understand the clinician’s concern and
rationale for wanting to prevent bacteremia. Multiple studies of moderate quality regarding
prophylaxis for the prevention of bacteremia post dental procedure suggest that antibiotic and
topical antimicrobial prophylaxis are effective in reducing the rate of bacteremia after simple
tooth extraction. There was insufficient data to investigate the effects of prophylaxis in regard to
other dental procedure groups via a meta-analysis. However, simple tooth extraction resulted in
the second highest median incidence of bacteremia and the highest median prevalence of
bacteremia for all procedure groups (see Figure 2 & Figure 4). Table 24 describes the included
studies related to antibiotic prophylaxis for the prevention of bacteremia upon tooth extraction.
Table 25 describes the included studies related to topical antimicrobials for the prevention of
bacteremia upon tooth extraction.
We performed network meta-analyses in order to determine which prophylactic treatments are

most effective. An initial attempt was made to combine both antibiotics and topical
antimicrobials into a single network meta-analysis. The exact cause of the inconsistency could
not be determined and therefore all results of antibiotic and topical antimicrobial prophylaxis are
presented independent of one another. The implication of this inconsistency is that formal (as
well as casual) indirect comparisons of treatment effects can be misleading and are thus avoided
in this clinical practice guideline. See Table 62 in the Appendix XI for results of the consistency
check. Further details on the results of these independent network meta-analyses are presented in
Recommendation 1 and Recommendation 2.


RESULTS
Table 24 Antibiotic prophylaxis and tooth extraction bacteremia
Study N Strength Outcome Active Antibiotic Control Route of Time of Results
(specific type) (%, n/N) (%, n/N) Administration Administration
Lockhart 179 High Bacteremia Amoxicillin (56%, Placebo Oral 1 hour before Favors
2008 50/90) (80%, procedure Amoxicillin
71/89)
Lockhart 100 High Bacteremia Amoxicillin (33%, Placebo Oral elixir 1 hour before Favors
2004 16/49) (84%, intubation Amoxicillin
43/51)
Aitken 40 Moderate Bacteremia Erythromycin N/A Oral 1-1.5 hours Favors
1995 (60%, 12/20) before procedure Clindamycin over
Clindamycin Erythromycin
(40%, 8/20)
Cannell 60 Moderate Bacteremia Erythromycin Placebo Oral 1-1.5 hours Erythromycin and
1991 (60%, 13/20) (65%, before procedure Josamycin
Josamycin (70%, 13/20) marginally more
14/20) effective than
placebo
Casolari 106 Moderate Bacteremia Penicillin (48%, No Oral 1 hour before Favors Penicillin
1989 12/25) Antiseptic Treatment procedure and Antiseptic
rinse (44%, 11/25) (67.9%, over control
38/56)
Coulter 58 Moderate Bacteremia Penicillin or No Intramuscular Unclear Favors Antibiotics
1990 Amoxicillin or Treatment (Penicillin), over control
Amoxicillin or (63%, Oral
Erythromycin 20/32) (Amoxicillin),
(35%, 9/26) Intravenous
(Amoxicillin),
Intravenous
(Erythromycin)

221 Moderate Bacteremia Amoxicillin No Oral 1-2 hours before Favors
(46.4%, 26/56) Treatment procedure Amoxicillin over
Clindamycin (96.2%, control and
(85.1%, 46/54) 51/53) Clindamycin,
Moxifloxacin Favors
Diz 2006 (56.9%, 33/58) Moxifloxacin over
control and
Clindamycin
Hall 1996 39 Moderate Bacteremia Cefaclor (79%, Placebo Oral 1 hour before No difference
16/20) (85%, procedure
16/19)
Bacteremia Cefaclor (79%, Placebo Oral 1 hour before No difference
(viridans 16/20) (50%, procedure
streptococci) 10/19)
Bacteremia Cefaclor (74%, Placebo Oral 1 hour before No difference
(anaerobic) 15/20) (75%, procedure
14/19)
Hall 1996 38 Moderate Bacteremia Erythromycin N/A Oral 1.5 hours before No difference
(79%, 15/19) procedure
Clindamycin
(84%, 16/19)
38 Bacteremia Erythromycin N/A Oral 1.5 hours before No difference
(viridans (79%, 15/19) procedure
streptococci) Clindamycin
(74%, 14/19)
Hall 1993 60 Moderate Bacteremia Penicillin (90%, Placebo Oral 1 hour before No difference
18/20) (95%, procedure
Amoxicillin (85%, 19/20)
17/20)
60 Bacteremia Penicillin (70% Placebo Oral 1 hour before No difference
(viridans 14/20) (70%, procedure
streptococci) Amoxicillin (55%, 14/20)
11/20)

60 Bacteremia Penicillin (85%, Placebo Oral 1 hour before No difference
(anaerobic) 17/20) (85%, procedure
Amoxicillin (75%, 17/20)
15/20)
Head 1984 65 Moderate Bacteremia Penicillin V (20%) Placebo Oral 1 hour before Favors Penicillin
(anaerobic) Metronidazole (84%) procedure over
(52%) Metronidazole
Jokinen 152 Moderate Bacteremia Penicillin (40%, No Oral (Penicillin), 45-90 minutes Favors
1970 15/38) Penicillin Treatment topical (local before procedure prophylaxis
with local (87%, prophylaxis) PLUS daily doses
prophylaxis (5%, 66/76) prior to operation
2/38) day (penicillin)
Khairat 242 Moderate Bacteremia Erythromycin No Oral 1.5-4 hours Favors
1966 250mg (37.5%, Treatment (Erythromycin), before procedure prophylaxis
6.16) (64%, Intravenous (Erythromycin),
Erythromycin 64/100) (Tetracycline) 3 minutes before
500mg (41%, procedure
7/17) (Tetracycline)
Erythromycin
1000mg (33%,
3/9)
Tetracycline (3%,
3/100)
Maskell 30 Moderate Bacteremia Teicoplanin (60%, No Intramuscular 1 hour before Favors
1986 6/10) Amoxicillin Treatment (Teicoplanin), procedure Amoxicillin over
(40%, 4/10) (100%, Oral Teicoplanin over
10/10) (Amoxicillin) control
Roberts 94 Moderate Bacteremia Amoxicillin (2%, No Oral 2 hours before Favors
1987 1/47) Treatment procedure Amoxicillin
(38%,
18/47)

Shanson 120 Moderate Bacteremia Amoxicillin (25%, No Intramuscular 25-40 minutes Favors
1987 (viridans 10/40) Treatment (Amoxicillin), before procedure Teicoplanin over
streptococci) Teicoplanin (32.5%, Intravenous (Amoxicillin), Amoxicillin over
(2.5%, 1/40) 13/40) bolus 5-10 minutes control
(Teicoplanin) before procedure
(Teicoplanin)
Shanson 82 Moderate Bacteremia Erythromycin Placebo Oral 1 hour before Favors
1985 (streptococcal) (15%, 6/40) (43%, procedure Erythromycin
18/42)
Shanson 120 Moderate Bacteremia Penicillin V (12%, No Oral 1 hour before Favors Penicillin
1978 (streptococcal) 5/40) Amoxicillin Treatment procedure and Amoxicillin
(5%, 2/40) (40%, over control
16/40)
60 Bacteremia Penicillin V (20%, No Oral 1 hour before Favors Penicillin
(anaerobic) 4/20) Amoxicillin Treatment procedure and Amoxicillin
(15%, 3/20) (50%, over control
10/20)
60 Bacteremia Penicillin (20%, No Oral 1 hour before Favors Penicillin
4/20) Amoxicillin Treatment procedure and Amoxicillin
(25%, 5/20) (70%, over control
14/20)
Vergis 29 Moderate Bacteremia Oral Amoxicillin No Oral, Rinse 1 hour before Favors oral
2001 (10%, 1/10) Treatment procedure (Oral), Amoxicillin over
Topical (89%, 8/9) 1 and 2 hours topical and control
Amoxicillin (60%, before procedure
6/10) (Rinse)
36 Bacteremia Oral Amoxicillin No Oral, Rinse 1 hour before Favors oral
(intent-to- (9%, 1/11) Treatment procedure (Oral), Amoxicillin over
treat) Topical (90%, 9/10) 1 and 2 hours topical and control
Amoxicillin (53%, before procedure
8/15) (Rinse)

DeVries 200 Low Bacteremia Lincomycin (8%, No Oral Daily for 3 days Favors
1972 2/25) Treatment AND 1 hour Lincomycin and
Clindamycin (49%, before procedure Clindamycin over
Prolonged (0%, 49/100) (lincomycin), control
0/25) Daily for 3 days
Clindamycin Short AND 2 hours
(8%, 4/50) before procedure
(prolonged
Clindamycin), 2
hours before
procedure (short
Clindamycin)
Wahlmann 60 Low Bacteremia Cefuroxime (33%, Placebo Intravenous 10 minutes Favors
1999 10/30) (86%, before procedure Cefuroxime
25/30)
Table 25 Topical antimicrobials and tooth extraction bacteremia

Study N Strength Outcome Active Treatment Control Application Results
(n/N, %) (n/N, %)
Lockhart 70 High Bacteremia Chlorhexidine Placebo Mouth rinse No difference
1996 (31/37, 84%) (31/33,
94%)
Casolari 106 Moderate Bacteremia Chlorhexidine OR No Irrigation of gingival Favors Chlorhexidine and
1989 Povidone-iodine treatment crevice and retention of Povidone-Iodine over
(11/25, 44%) (38/56, solution in mouth for a control
Penicillin 68%) few minutes
antibiotic (12/25,
48%)

(n/N, %) (n/N, %)
Jokinen 152 Moderate Bacteremia Organic Iodine N/A Mouth rinse No difference
1978 (21/38, 55%)
Operative Field
Isolation (13/38,
34%)
Isolation+Iodine
(12/38, 32%)
Isolation+Chlorhex
(5/38, 13%)
Macfarlane 60 Moderate Bacteremia Chlorhexidine Saline Irrigation of gingival Favors Povidone-Iodine over
1984 (5/20, 25%) (16/20, crevice and retention of saline, Favors Chlorhexidine
Povidone-Iodine 80%) solution in mouth for a over saline
(8/20, 40%) few minutes
Rahn 1995 120 Moderate Bacteremia Chlorhexidine Water Irrigation of gingival Favors Povidone-Iodine
(18/40, 45%) (21/40, crevice and retention of
Povidone-Iodine 52.5%) solution in mouth for a
(11/40, 27.5%) few minutes
Scopp 64 Moderate Bacteremia Povidone-Iodine Placebo Mouth rinse and irrigation Favors Povidone-Iodine
1971 (9/32, 28%) (18/32, of gingiva rinse over placebo
56%)
Sweet 100 Moderate Bacteremia Chloramine-T No Chloramine-T rinse and Favors Chloramine-T (brush
1978 rinse (12/25, 48%) Treatment brushing, Irrigation with or rinse) over control and
Chloramine-T (21/25, Lugol's solution Lugol's solution
brush (12/25, 48%) 84%)
Lugol's solution
(20/25, 80%)
Tomas 106 Moderate Bacteremia Chlorhexidine No Mouth filled Favors Chlorhexidine
2007 (42/53, 79%) Treatment
(51/53,
96%)
Cutcher 100 Low Bacteremia Phenolated (27/50, No Mouth rinse Favors Phenolated rinse
1971 54%) Treatment
(39/50,
78%)

(n/N, %) (n/N, %)
Francis 175 Low Bacteremia Sodium perborate- No Mouth rinse and irrigation Favors Sodium perborate-
1973 ascorbic acid Treatment of gingival sulcus ascorbic acid over saline and
(9/50, 18%) (51/100, no treatment
51%) Saline
(15/25,
60%)
Jones 1970 201 Low Bacteremia Phenolated (12/67, No Mouth rinse and irrigation Favors Phenolated rinse over
18%) Treatment of gingival sulcus control, Favors saline rinse
(44/67, over control
66%) Saline
(31/67,
46%)
Nasif 1977 120 Low Bacteremia Hydrogen No Irrigation of gingival Favors Hydrogen Peroxide
Peroxide (13/60, Treatment sulcus
22%) (26/60,
43%)
Yamalik 80 Low Bacteremia Povidone-Iodine No Irrigation of gingival Favors Povidone-Iodine over
1992 (941) (7/20, 35%) Treatment sulcus control
Hydrogen peroxide (14/20,
(10/20, 50%) 70%)
Chlorhexidine
(8/20, 40%)

INDIRECT EVIDENCE: BACKGROUND MICROBIOLOGY
FINDINGS
There was no direct evidence to explain the proposed association between bacteremia and
orthopaedic implant infection, therefore we summarized the microbiological information
pertaining to cases and rates of bacteremia and implant infection when available. Thirteen
orthopaedic implant cohort studies were included that followed up on almost 13,000 implants,
twelve of which provided detailed information on any infections that resulted over the course of
the study. Approximately 53% of organisms responsible for the infections were Staphylococcus
species. Overall rate of infection was approximately 1.5%. Of the studies that distinguished early
from late infections we were able to calculate rates of 0.4% and 0.9% respectively. The
definition of late infection varied greatly. In some cases it was not defined and in others it ranged
from >3months to >18months. See Table 26 and 26 for details.
Eighteen studies addressing only infected orthopaedic implants were included and totaled
approximately 1090 cases of implant infections. All eighteen studies provided detailed
information on the infection. Approximately 64% of the infections were Staphylococcus species.
Of the studies that distinguished early from late infections, 36.7% were early and 63.3% were
late. The definition of late infection varied greatly. It ranged from >4 weeks to >1 year. See
Table 27 and Figure 7 for details.
Incidence and prevalence of bacteremia varied greatly by procedure and study, as did the
organism responsible for the bacteremia. Data is presented by procedure group. For studies that
provided the necessary information, data were pooled and represent the proportion of bacteremic
study participants that were found positive for the respective infecting organism. Microbiology
data that was available from patients who received a form of prophylaxis was not included. No
clear association between the organisms found in the prosthetic implant infections and
bacteremia exists. However, the majority of the organisms found in implant infections are
Staphylococcus and the majority of the organisms found as the cause of bacteremias are
Streptococcus. See Figure 8 - Figure 34 for microbiological details on bacteremia.

RESULTS
Table 26 Orthopaedic implant cohort studies
% Late
Infected Population Early Late % Late Infection
Author Year Implant Study N N Infected Infection Infection infection Criteria
Ainscow 1984 Hip & 1112 22 2.0% 11 11 1.0% ≥3 months
Knee
Choong 2007 Hip 819 14 1.7% NA NA NA NA
Goodman 2006 Hip 17 1 5.9% NA NA NA NA
Hamilton 2008 Hip & 1993 29 1.5% 11 18 0.9% ≥3 months

Knee
Klenerman 1991 Hip & 174 2 1.1% 0 2 1.1% ≥3 months
Knee
Mont 1999 Hip 109 1 0.9% NA NA NA NA
Petrie 1998 Knee 1837 40 2.2% NA NA NA NA
Sancheti 2009 Knee 297 1 0.3% 0 1 0.3% ≥7 months

Smith 1997 Hip 66 2 3.0% 0 2 3.0% ≥18
months
Soultanis 2003 Spine 60 5 8.3% NA 5 8.3% ≥1 year
Uckay 2009 Hip & 6101 71 1.2% 21 50 0.8% ≥3 months
Knee
Wagner 2000 Hip 78 1 1.3% 0 1 1.3% NA
Wimmer 1998 Spine 110 1 0.9% 0 1 0.9% ≥17
months

Figure 6 Organisms cultured from cohort studies

Table 27 Orthopaedic implant case series studies
Late
Early Late % Late Infection
Author Year Site Study N Infected N Infection Infection Infection Criteria
Berbari 2009 Hip & Knee 339 339 151 188 55.5% ≥12 months
Chiu 2007 Knee 40 40 10 30 75.0% ≥4 weeks

Cordero- 2009 Hip 36 36 0 36 100.0% ≥3 months
Ampuero
Cordero- 2007 Hip & Knee 40 40 0 40 100.0% ≥3 months
Ampuero
Crockarell 1998 Hip 42 42 19 23 54.8% ≥1 month
Fink 2008 Knee 40 40 0 40 100.0% ≥2 months
Hoad-Reddick 2005 Knee 59 59 NA NA NA NA
Insall 1983 Knee 11 11 3 8 72.7% ≥3 months
Jerosch 2003 Shoulder 12 12 2 10 83.3% 4 weeks
Mont 1997 Knee 24 24 10 14 58.3% ≥29 days
Munoz- 2011 Hip, Knee, 79 79 69 10 12.7% ≥3 months
Mahamud Other
Rao 2003 Hip, Knee, 36 36 13 23 63.9% ≥1 year

Elbow
Rodriguez 2009 Hip , Knee, 50 50 0 50 100.0% ≥5 years
Shoulder
Soriano 2007 Knee, Hip, 85 85 NA NA NA NA
Shoulder,
other
Soriano 2006 Hip & Knee 47 47 NA NA NA NA
Waldman 2000 Knee 16 16 4 12 75.0% ≥6 months

Windsor 1990 Knee 29 29 NA NA NA NA
Wroblewski 1986 Hip 102 102 NA NA NA NA

Figure 7 Organisms cultured from case series studies

Figure 8 Brushing Bacteria (Incidence) Figure 9 Brushing Bacteria (Prevalence)
S. aureus Staphylococcus S. aureus

8.0%
S. epidermidis S. epidermidis
Other
Staphylococcus Staphylococcus
11.1%
S. viridans (oral flora) S. viridans (oral flora)
S. mitis (oral flora) S. mitis (oral flora)
S. mutans (oral flora) Gram Negative S. mutans (oral flora)
28.0% S. viridans
S. mitis Streptococcus (potential oral flora) 20.0% Streptococcus (potential oral flora)
44.4%
E. coli E. coli
Streptococcus E. faecalis E. faecalis

33.3% Enterococcus Enterococcus
P. aeruginosa Gram Positive S. mitis P. aeruginosa
12.0% 4.0%
Pseudomonas Pseudomonas
Enterobacter Enterobacter
Streptococcus
S. mutans Gram Positive Gram Positive
28.0%
11.1% Gram Negative Gram Negative
Other Other
Study Total N Infected N Rate Study Total N Infected N Rate

Forner 2006 60 2 3.3% Lucas 2000 52 20 38.5%
Sconyers 1973 30 5 16.7% Silver 1979 36 3 8.3%

Figure 10 Cleft Palate Bacteria (Prevalence) Figure 11 Dental Implant Bacteria (Incidence)
S. aureus S. aureus
Streptococcus S. viridans (oral flora) S. viridans (oral flora)
16.7%
S. mutans (oral flora) S. mutans (oral flora)
Streptococcus (potential oral flora) Streptococcus (potential oral flora)
E. coli E. coli
Gram Negative S. mitis
E. faecalis 50.0% 50.0% E. faecalis
Enterococcus Enterococcus
P. aeruginosa P. aeruginosa
S. epidermidis Pseudomonas Pseudomonas
83.3%
Gram Positive Gram Positive
Gram Negative Gram Negative
Other Other

Marzoni 1983 14 6 42.9% Pineiro 2010 30 2 6.7%

Figure 12 Dental Prophylaxis Bacteria (Incidence) Figure 13 Dental Prophylaxis Bacteria (Prevalence)
S. viridans Gram Negative

S. aureus S. aureus
2.7% Gram Positive 5.6%
S. epidermidis 5.6% S. epidermidis
S. mitis Staphylococcus Staphylococcus
5.4%
Gram Negative
S. aureus
24.3% S. mutans (oral flora) S. mutans (oral flora)
33.3%
E. coli E. coli
E. faecalis E. faecalis
Streptococcus
39.6% Enterococcus Enterococcus
Gram Positive
S. viridans
27.9% Pseudomonas Pseudomonas
50.0%
Gram Positive S. Gram Positive
epidermidis
5.6%
Other Other

Cherry 2007 60 11 28.2% Windslow 1960 72 17 23.6%
Forner 2006 20 15 75.0%
Heimdahl 1990 20 14 70.0%

Figure 14 Endodontic Bacteria (Incidence) Figure 15 Endodontic Bacteria (Prevalence)
S. aureus S. aureus
Other
S. aureus Staphylococcus Staphylococcus
Gram Negative 8.3%
9.5%
9.5% S. viridans (oral flora) Streptococcus S. viridans (oral flora)
16.7%
E. coli E. coli
Gram Negative
Gram Positive E. faecalis E. faecalis
33.3%
33.3%
Streptococcus Enterococcus Enterococcus
42.9% P. aeruginosa P. aeruginosa
Gram Positive
Pseudomonas 41.7% Pseudomonas
E. faecalis
4.8% Other Other

Baumgartner
1976 30 1 3.3% Debelian 1995 26 11 42.3%
Baumgartner
1977 12 7 58.3%
Heimdahl 1990 20 4 20.0%

Figure 16 Injection Bacteria (Incidence) Figure 17 Inter-dental Cleaning Bacteria (Incidence)
S. epidermidis
2.7%
S. aureus
S. aureus 2.7% S. aureus
Staphylococcus
S. viridans
14.9% S. viridans (oral flora) Gram Negative S. viridans (oral flora)
S. mitis (oral flora) 16.2% S. mitis (oral flora)
S. viridans
S. mutans (oral flora) 6.8% S. mutans (oral flora)
Gram Negative Streptococcus Streptococcus (potential oral flora) Streptococcus (potential oral flora)
36.8% 8.0% S. mitis
E. coli 6.8% E. coli
Enterococcus Gram Positive Enterococcus
29.7%
Streptococcus
Gram Positive 28.4%
40.2% Enterobacter Enterobacter
Other Other

Rahn 1994 40 21 52.5% Berger 1974 30 9 18.0%
Crasta 2009 59 24 40.7%
Felix 1971 30 15 50.0%
Ramadan 1975 50 9 18.8%
Romans 1971 30 1 6.7%
Wank 1976 21 6 28.6%

Figure 18 Intubation Bacteria (Incidence) Figure 19 Oral Surgery Bacteria (Incidence)
S. epidermidis
S. aureus 5.3%
S. aureus S. mutans S. aureus
3.3%
Gram Negative Staphylococcus Staphylococcus

10.0% Gram Negative
13.2%
Gram Positive
10.0%
Streptococcus (potential oral flora) Streptococcus Streptococcus (potential oral flora)
Staphylococcus E. coli 23.7% E. coli
36.7%
Streptococcus
20.0%
Gram Positive
Pseudomonas 52.6% E. faecalis Pseudomonas
2.6%
S. viridans Gram Positive Gram Positive

Other Other

Berry 1973 50 4 8.0% Flood 1990 17 3 17.6%
Dinner 1987 54 3 5.6% Heimdahl 1990 20 11 55.0%
Hansen 1989 19 1 5.3%
Oncag 2005 74 9 12.2%
Valdes 2008 110 13 11.8%

Figure 20 Oral Surgery Bacteria (Prevalence) Figure 21 Orthodontic Bacteria (Incidence)
Gram Negative
3.7% S. aureus
3.7% S. aureus S. aureus
Staphylococcus S. aureus Staphylococcus
9.1%
S. viridans (oral flora) Gram Positive S. viridans (oral flora)
S. mitis (oral flora) 18.2% S. mitis (oral flora)
Staphylococcus
Gram Positive Staphylococcus
25.9% 25.9% Streptococcus (potential oral flora) Streptococcus (potential oral flora)
S. mitis
P. aeruginosa Streptococcus P. aeruginosa
Pseudomonas 36.4% S. mutans Pseudomonas
18.2%
S. mitis Gram Positive Gram Positive
Streptococcus 37.0%
Other Other

Martin 1964 50 27 54.0% Erverdi 1999 40 3 7.5%
Gurel 2009 25 8 32.0%

Figure 22 Orthodontic Bacteria (Prevalence) Figure 23 Periodontic [Scaling & Planing] Bacteria
(Incidence)
S. mitis
S. aureus S. viridans 2.5%
Staphylococcus
0.8% S. mutans
S. epidermidis 0.8% S. aureus
1.7%
Staphylococcus S. epidermidis
Gram Negative
11.1% S. mitis S. viridans (oral flora) Staphylococcus
22.2%
S. mitis (oral flora) S. viridans (oral flora)
Gram Positive S. mutans (oral flora) Streptococcus S. mitis (oral flora)
11.1% 11.6%
Streptococcus (potential oral flora) S. mutans (oral flora)
E. coli Streptococcus (potential oral flora)
S. mutans E. faecalis E. coli
11.1% Enterococcus
Gram Negative E. faecalis
P. aeruginosa 52.9% Enterococcus
Gram Positive
Pseudomonas 29.8% P. aeruginosa
Streptococcus
44.4% Enterobacter Pseudomonas
Gram Positive Enterobacter
Gram Negative Gram Positive
Other Gram Negative
Other

Burden 2004 30 4 13.3% Casolari 1989 42 12 28.6%
Lafaurie 2007 42 34 81.0%
Lucartorto 1992 41 13 31.7%
Morozumi 2010 10 9 90.0%
Waki 1990 15 2 13.3%

Figure 24 Periodontic [Gingivectomy] Bacteria (Incidence) Figure 25 Periodontic [Probing] Bacteria (Incidence)
Other
S. aureus S. aureus
3.2%
S. mitis (oral flora) Gram Negative S. mitis (oral flora)
Streptococcus
32.3% Streptococcus (potential oral flora) Streptococcus (potential oral flora)
E. coli Streptococcus E. coli
46.2%
Gram Negative
Gram Positive
Pseudomonas 30.8% Pseudomonas
Gram Positive
Other Other

Rogosa 1960 13 12 92.3% Daly 2001 40 10 25.0%

Figure 26 Periodontic [Scaling & Planing] Bacteria Figure 27 Periodontic [Gingivectomy] Bacteria (Prevalence)
(Prevalence)
Staphylococcus
2.6% S. aureus
Other S. epidermidis
S. aureus
2.6%
S. epidermidis Other Staphylococcus
Gram Positive S. aureus
Gram 16.7% S. viridans (oral flora)
Staphylococcus 4.2% 16.7%
Negative
S. aureus S. viridans (oral flora) S. mitis (oral flora)
7.7%
20.5% S. mutans (oral flora)
S. mitis (oral flora)
S. mutans (oral flora) Streptococcus (potential oral flora)
Streptococcus (potential oral flora) E. coli

Streptococcus
E. coli 8.3% E. faecalis
Gram Positive S. viridans
5.1% E. faecalis Enterococcus
30.8%
Enterococcus P. aeruginosa
P. aeruginosa Pseudomonas
Pseudomonas S. viridans Enterobacter

54.2%
S. mitis Gram Positive
Enterobacter
23.1%
Gram Positive Gram Negative
Gram Negative Other

Streptococcus
Other
7.7%

Conner 1967 109 38 34.9% Gutverg 1962 67 24 35.8%

Figure 28 Periodontic [Probing] Bacteria (Prevalence) Figure 29 Sialography Bacteria (Prevalence)
S. aureus S. aureus
S. viridans (oral flora) Gram Positive S. viridans (oral flora)
Staphylococcus 14.3%
18.2% S. mitis (oral flora) S. aureus S. mitis (oral flora)
Gram Negative 28.6%
27.3%
S. viridans Streptococcus
9.1%
Streptococcus
Gram Positive Enterobacter Enterobacter

36.4% Gram Positive Staphylococcus Gram Positive
42.9%
Other Other

Kinane 2005 30 5 16.7% Lamey 1985 30 7 23.3%

Figure 30 Suture Bacteria (Incidence) Figure 31 Suture Bacteria (Prevalence)
S. aureus S. aureus
S. viridans Staphylococcus Staphylococcus
Gram Negative
11.1%
11.1% S. viridans (oral flora) S. viridans (oral flora)
S. mitis
S. mitis (oral flora) Gram Positive 25.0% S. mitis (oral flora)
Gram Positive S. mutans (oral flora) 25.0% S. mutans (oral flora)

11.1% Streptococcus (potential oral flora) Streptococcus (potential oral flora)
E. coli E. coli
Streptococcus
66.7%
Gram Positive Streptococcus Gram Positive
50.0%
Other Other

Brown 1998 24 2 8.3% Giglio 1992 25 4 16.0%
King 1988 20 1 5.0%
Wampole 1978 20 5 25.0%

Figure 32 Teething Bacteria (Prevalence) Figure 33 Tooth Extraction Bacteria (Incidence)
Staphylococcus
Other 0.4%
S. aureus
0.8%
0.8%
S. aureus S. aureus
Streptococcus S. viridans (oral flora) S. viridans S. viridans (oral flora)
15.4% 18.1%
S.
S. mutans (oral flora) mutans S. mutans (oral flora)
1.6% Streptococcus (potential oral flora)
Staphylococcus Streptococcus (potential oral flora) Gram Negative
38.5% 36.6% E. coli
E. coli
Enterococcus Streptococcus Enterococcus
P. aeruginosa 22.2% P. aeruginosa
S. viridans Pseudomonas Pseudomonas

46.2% Enterobacter Enterobacter
Gram Positive Gram Positive Gram Positive
18.9%
E. faecalis
Other 0.4% Other

Soliman 1977 40 13 32.5% Heimdahl 1990 20 20 100.0%
Khairat 1966 100 64 64.0%

Figure 34 Tooth Extraction Bacteria (Prevalence)
Staphylococcus
3.6%
S. viridans S. aureus
1.4%
S. epidermidis
Staphylococcus
S. mitis
7.7% S. viridans (oral flora)
S. mitis (oral flora)
Gram Negative S. mutans (oral flora)
29.5%
Streptococcus (potential oral flora)
E. coli
E. faecalis
Streptococcus
32.3% Enterococcus
P. aeruginosa
Pseudomonas
Gram Positive Enterobacter
25.5%
Gram Positive
Gram Negative
Other
Study Total N Infected N Rate

Crawford 1973 25 23 92.0%
Maskell 1986 10 10 100.0%
Peterson 1976 80 39 48.8%
Shanson 1978 40 16 40.0%
Shanson 1987 40 13 32.5%

RECOMMENDATIONS
The following recommendations are 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.

RECOMMENDATION 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

Description: 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. 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.
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.
RATIONALE
Moderate strength evidence finds that dental procedures are unrelated to implant infection and
that antibiotic prophylaxis prior to dental procedures does not reduce the risk of subsequent
implant infection. There is no direct evidence to support otherwise. High strength evidence
suggests that antibiotic prophylaxis reduces the incidence of post-dental procedure related
bacteremia, but there is no evidence that these bacteremias are related to prosthetic joint
infections.
A single well-conducted case-control study provides direct evidence for this recommendation.39
Case-control studies are appropriate to answer questions regarding risk factors or etiology.
Study enrollment consisted of 339 patients with prosthetic hip or knee infections (cases) and 339
patients with hip or knee arthroplasties without infection (controls) hospitalized on an
orthopaedic service during the same time period. The comparison between these groups was for
differences in dental visits (exposure) in terms of high and low-risk dental procedures, with and
without antibiotic prophylaxis. Results reported as odds ratios with 95% confidence interval,
demonstrate no statistically significant differences between groups. Neither dental procedures
nor antibiotic prophylaxis prior to dental procedures were associated with risk of prosthetic hip
or knee infections. The authors performed a sample size calculation and withdrawals were low,
minimizing attrition bias. The prospective nature of this study minimized recall bias.
Additionally, blinding of the treatment group to those assessing outcomes limits detection bias.
Although this one study of direct evidence was of moderate quality, it did have limitations. The
authors conducted covariate analysis on some subgroups of higher risk patients. The number of
patients in these subgroups, however, was relatively small, and there is insufficient data to
suggest that these patients are at higher risk of experiencing hematogenous infections.
There is high quality evidence that demonstrates the occurrence of bacteremia with dental
procedures. Historically, there has been a suggestion that bacteremias can cause hematogenous
seeding of total joint implants, both in the early postoperative period and for many years
following implantation. It was felt that the most critical period was up to two years after joint

placement. In addition, bacteremias may occur during normal daily activities such as chewing
and tooth brushing. It is likely that these daily activities induce many more bacteremias than
dental procedure associated bacteremias. While evidence supports a strong association between
certain dental procedures and bacteremia, there is no evidence to demonstrate a direct link
between dental procedure associated bacteremia and infection of prosthetic joints or other
orthopaedic implants. Multiple studies of moderate and high quality evidence suggest that
antibiotic prophylaxis decreases the risk of dental procedure associated bacteremias. However,
dental procedure associated bacteremia is a surrogate outcome for prosthetic joint infection.
Surrogate outcomes may or may not relate to a clinically relevant patient outcome. Of additional
concern is a positive surrogate outcome (e.g. reduced bacteremias) that could mask a negative
patient-centered outcome (e.g. implant infection).
This recommendation is limited to patients with hip and knee prostheses because the single study
of direct evidence included only patients with these types of orthopaedic implants. There is no
direct evidence that met our inclusion criteria for patients with other types of orthopaedic
implants.
FINDINGS
As illustrated in Figure 1 there is varying quality of evidence that explains the purported
association between dental procedures and orthopaedic implant infection. Only one moderate
quality study of direct evidence was considered for this recommendation. The results of this
study conclude that dental procedures are not risk factors for subsequent orthopaedic implant
infection and furthermore that antibiotic prophylaxis prior to dental procedures does not reduce
the risk of implant infection. However, multiple high quality studies of indirect evidence link
oral procedures to bacteremia (see Figure 2 - Figure 5). Furthermore, multiple moderate quality
studies of indirect evidence suggest that antibiotic prophylaxis prevents post-dental procedure
bacteremia. Details of our analysis on antibiotic prophylaxis are presented in the results section
below.

NETWORK META-ANALYSIS
Of the 21 studies included for this recommendation, 2 were of high quality and moderate
applicability, 17 were of moderate quality and moderate applicability, and 2 were of low quality
and moderate applicability. For details see Table 69 and Table 75 of Appendix XII.
RESULTS
Twenty one studies that investigated the efficacy of antibiotic prophylaxis for prevention of
dental procedure related bacteremia were included that compared antibiotics to controls or other
antibiotics. Direct and indirect comparisons were drawn from network meta-analysis as
diagramed in Figure 35. The network meta-analysis allowed us to compare treatments that were
not in the same study. More detailed information on this method can be found in the “Statistical
Methods” section of this guideline. Table 28, Table 29, and Table 30 summarize the results of
these comparisons. Figure 36 and Figure 37 graphically depict the direct and indirect antibiotic
comparisons vs. placebo/no treatment. Odds ratios were converted to number needed to treat

(NNT) for a more clinically meaningful interpretation (see Table 31). Rankings of the antibiotics
are presented in Table 32. These rankings do not indicate statistical significance.
The overall network model was consistent. See Table 59 in Appendix XI. Goodness-of-fit
statistics are also presented in Appendix XI (see
Table 61). These results suggest that our model fits the available data. Individual study results
can be found in Table 24. Individual study results that could not be meta-analyzed can be found
in Table 67 in Appendix XI.
Figure 35 Network Diagram of Antibiotic Prophylaxis for the Prevention of Dental-related

Bacteremia
Penicillin
1
Antiseptic Josamycin
Rinse 1 Erythromycin
3
Cefaclor 1 1 2
1 2
2 IV
Tetracycline
1 1
IV Placebo/No 2 Clindamycin
Cefuroxime
1 Treatment
1 1
1
IM Pen.
OR IV Moxifloxacin
Erythro.
1 1 8
OR IV or Oral
Amox. 1
IM
Teicoplanin
Amoxicillin 1
Topical 1
Amoxicillin
Circles denote the treatments studied. Lines between circles denote treatment comparisons that are
addressed by direct evidence. The numbers on these lines show the number of trials that compared the
two treatments denoted in the circles.

Table 28 Direct Comparisons of Antibiotic Prophylaxes for the Prevention of Dental-
related Bacteremia
Comparison Studies Odds Ratio (95% CI)
Amoxicillin vs. Placebo/No Treatment 8 0.093* (0.041, 0.212)
Penicillin vs. Placebo/No Treatment 3 0.282 (0.109, 0.731)
Erythromycin vs. Placebo/No Treatment 2 0.512 (0.188, 1.396)
Clindamycin vs. Placebo/No Treatment 2 0.121 (0.049, 0.299)
Josamycin vs. Placebo/No Treatment 1 1.256 (0.334, 4.733)
Moxifloxacin vs. Placebo/No Treatment 1 0.052 (0.011, 0.233)
Cefaclor vs. Placebo/No Treatment 1 0.75 (0.144, 3.903)
IV Tetracycline vs. Placebo/No Treatment 1 0.017 (0.005, 0.059)
IV Cefuroxime vs. Placebo/No Treatment 1 0.1 (0.029, 0.34)
IM Teicoplanin vs. Placebo/No Treatment 1 0.069 (0.003, 1.498)
Topical Amoxicillin vs. Placebo/No Treatment 1 0.127 (0.013, 1.269)
Antiseptic Rinse vs. Placebo/No Treatment 1 0.372 (0.141, 0.98)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs.
Placebo/No Treatment 1 0.318 (0.108, 0.935)
Penicillin vs. Amoxicillin 2 0.997 (0.308, 3.229)
Clindamycin vs. Amoxicillin 1 6.635 (2.654, 16.586)
Moxifloxacin vs. Amoxicillin 1 1.523 (0.728, 3.189)
IM Teicoplanin vs. Amoxicillin 1 2.25 (0.376, 13.465)
Topical Amoxicillin vs. Amoxicillin 1 11.429 (1.155, 113.115)
Antiseptic Rinse vs. Penicillin 1 0.851 (0.28, 2.591)
Clindamycin vs. Erythromycin 2 0.7 (0.23, 2.129)
Josamycin vs. Erythromycin 1 1.256 (0.334, 4.733)
IV Tetracycline vs. Erythromycin 1 0.05 (0.014, 0.186)
Moxifloxacin vs. Clindamycin 1 0.23 (0.092, 0.572)
*Heterogeneity (I2 >50%)

Figure 36 Forest Plot of Direct Comparisons of Antibiotics vs. Placebo/No Treatment for
the Prevention of Dental-related Bacteremia

Table 29 Indirect (Network) Comparisons of Antibiotic Prophylaxes for the Prevention of
Dental-related Bacteremia
Comparison Odds Ratio
Amoxicillin vs. Placebo/No Treatment 0.071 (0.026, 0.167)
Penicillin vs. Placebo/No Treatment 0.176 (0.042, 0.685)
Erythromycin vs. Placebo/No Treatment 0.426 (0.111, 1.593)
Clindamycin vs. Placebo/No Treatment 0.235 (0.063, 0.842)
Josamycin vs. Placebo/No Treatment 0.838 (0.093, 7.636)
Moxifloxacin vs. Placebo/No Treatment 0.068 (0.009, 0.447)
Cefaclor vs. Placebo/No Treatment 0.719 (0.047, 10.31)
IV Tetracycline vs. Placebo/No Treatment 0.016 (0.001, 0.146)
IV Cefuroxime vs. Placebo/No Treatment 0.089 (0.007, 0.952)
IM Teicoplanin vs. Placebo/No Treatment 0.099 (0.006, 1.266)
Topical Amoxicillin vs. Placebo/No Treatment 0.326 (0.028, 3.479)
Antiseptic Rinse vs. Placebo/No Treatment 0.239 (0.028, 1.899)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. Placebo/No
Treatment 0.301 (0.029, 3.064)
Penicillin vs. Amoxicillin 2.478 (0.594, 11.06)
Erythromycin vs. Amoxicillin 5.983 (1.345, 30.20)
Clindamycin vs. Amoxicillin 3.303 (0.816, 14.87)
Josamycin vs. Amoxicillin 11.77 (1.161, 134.5)
Moxifloxacin vs. Amoxicillin 0.968 (0.143, 6.753)
Cefaclor vs. Amoxicillin 10.10 (0.608, 180.9)
IV Tetracycline vs. Amoxicillin 0.226 (0.019, 2.615)
IV Cefuroxime vs. Amoxicillin 1.254 (0.099, 17.20)
IM Teicoplanin vs. Amoxicillin 1.393 (0.101, 17.27)
Topical Amoxicillin vs. Amoxicillin 4.585 (0.422, 52.35)
Antiseptic Rinse vs. Amoxicillin 3.363 (0.375, 32.49)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. Amoxicillin 4.229 (0.372, 54.81)
Erythromycin vs. Penicillin 2.413 (0.370, 16.34)
Clindamycin vs. Penicillin 1.333 (0.214, 8.542)
Josamycin vs. Penicillin 4.749 (0.368, 64.07)
Moxifloxacin vs. Penicillin 0.390 (0.038, 3.811)
Cefaclor vs. Penicillin 4.075 (0.198, 83.42)
IV Tetracycline vs. Penicillin 0.091 (0.006, 1.290)
IV Cefuroxime vs. Penicillin 0.506 (0.031, 8.068)
IM Teicoplanin vs. Penicillin 0.562 (0.028, 9.679)
Topical Amoxicillin vs. Penicillin 1.850 (0.119, 28.41)
Antiseptic Rinse vs. Penicillin 1.357 (0.163, 11.47)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. Penicillin 1.706 (0.118, 26.84)
Clindamycin vs. Erythromycin 0.552 (0.137, 2.181)
Josamycin vs. Erythromycin 1.968 (0.222, 17.81)
Moxifloxacin vs. Erythromycin 0.161 (0.016, 1.389)
Cefaclor vs. Erythromycin 1.688 (0.082, 33.61)
IV Tetracycline vs. Erythromycin 0.037 (0.003, 0.353)
IV Cefuroxime vs. Erythromycin 0.209 (0.013, 3.158)
IM Teicoplanin vs. Erythromycin 0.232 (0.010, 4.034)
Topical Amoxicillin vs. Erythromycin 0.766 (0.048, 11.33)
Antiseptic Rinse vs. Erythromycin 0.562 (0.045, 6.494)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. Erythromycin 0.707 (0.050, 10.30)

Comparison Odds Ratio
Josamycin vs. Clindamycin 3.564 (0.329, 39.80)
Moxifloxacin vs. Clindamycin 0.293 (0.037, 2.090)
Cefaclor vs. Clindamycin 3.055 (0.150, 60.82)
IV Tetracycline vs. Clindamycin 0.068 (0.005, 0.779)
IV Cefuroxime vs. Clindamycin 0.379 (0.024, 5.691)
IM Teicoplanin vs. Clindamycin 0.421 (0.021, 6.972)
Topical Amoxicillin vs. Clindamycin 1.388 (0.091, 19.96)
Antiseptic Rinse vs. Clindamycin 1.018 (0.085, 11.63)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. Clindamycin 1.280 (0.091, 18.65)
Moxifloxacin vs. Josamycin 0.082 (0.004, 1.368)
Cefaclor vs. Josamycin 0.857 (0.025, 27.41)
IV Tetracycline vs. Josamycin 0.019 (0.000, 0.373)
IV Cefuroxime vs. Josamycin 0.106 (0.004, 2.789)
IM Teicoplanin vs. Josamycin 0.118 (0.003, 3.333)
Topical Amoxicillin vs. Josamycin 0.389 (0.014, 9.954)
Antiseptic Rinse vs. Josamycin 0.285 (0.013, 5.870)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. Josamycin 0.359 (0.014, 8.688)
Cefaclor vs. Moxifloxacin 10.43 (0.386, 301.8)
IV Tetracycline vs. Moxifloxacin 0.233 (0.012, 4.379)
IV Cefuroxime vs. Moxifloxacin 1.295 (0.061, 28.38)
IM Teicoplanin vs. Moxifloxacin 1.438 (0.056, 31.72)
Topical Amoxicillin vs. Moxifloxacin 4.735 (0.237, 100.0)
Antiseptic Rinse vs. Moxifloxacin 3.472 (0.211, 60.64)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. Moxifloxacin 4.366 (0.230, 95.01)
IV Tetracycline vs. Cefaclor 0.022 (0.000, 0.756)
IV Cefuroxime vs. Cefaclor 0.124 (0.003, 4.517)
IM Teicoplanin vs. Cefaclor 0.137 (0.002, 5.562)
Topical Amoxicillin vs. Cefaclor 0.454 (0.012, 16.46)
Antiseptic Rinse vs. Cefaclor 0.333 (0.011, 10.07)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. Cefaclor 0.418 (0.012, 14.52)
IV Cefuroxime vs. IV Tetracycline 5.551 (0.208, 150.8)
IM Teicoplanin vs. IV Tetracycline 6.165 (0.174, 189.2)
Topical Amoxicillin vs. IV Tetracycline 20.28 (0.735, 561.7)
Antiseptic Rinse vs. IV Tetracycline 14.87 (0.686, 330.9)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. IV Tetracycline 18.70 (0.769, 484.9)
IM Teicoplanin vs. IV Cefuroxime 1.110 (0.028, 35.26)
Topical Amoxicillin vs. IV Cefuroxime 3.658 (0.116, 107.7)
Antiseptic Rinse vs. IV Cefuroxime 2.682 (0.109, 62.67)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. IV Cefuroxime 3.370 (0.120, 96.44)
Topical Amoxicillin vs. IM Teicoplanin 3.293 (0.108, 117.0)
Antiseptic Rinse vs. IM Teicoplanin 2.415 (0.093, 75.71)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. IM Teicoplanin 3.034 (0.098, 116.1)
Antiseptic Rinse vs. Topical Amoxicillin 0.733 (0.031, 17.77)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. Topical Amoxicillin 0.922 (0.034, 28.33)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. vs. Antiseptic Rinse 1.257 (0.056, 29.51)

Table 30 Indirect (Network) Significant Comparisons of Antibiotic Prophylaxes for the
Prevention of Dental-related Bacteremia
Comparison
Amoxicillin favored over Placebo/No Treatment
Penicillin favored over Placebo/No Treatment
Clindamycin favored over Placebo/No Treatment
Moxifloxacin favored over Placebo/No Treatment
IV Tetracycline favored over Placebo/No Treatment
IV Cefuroxime favored over Placebo/No Treatment
Amoxicillin favored over Erythromycin
Amoxicillin favored over Josamycin
IV Tetracycline favored over Erythromycin
IV Tetracycline favored over Clindamycin
IV Tetracycline favored over Josamycin
IV Tetracycline favored over Cefaclor
Figure 37 Forest Plot of Indirect (Network) Comparisons of Antibiotics vs. Placebo/No

Treatment for the Prevention of Dental-related Bacteremia
Odds
Prophylaxis Ratio (95% CI)
Amoxicillin 0.07 (0.03, 0.17)

Penicillin 0.18 (0.04, 0.69)
Erythromycin 0.43 (0.11, 1.59)
Clindamycin 0.24 (0.06, 0.84)
Josamycin 0.84 (0.09, 7.64)
Moxifloxacin 0.07 (0.01, 0.45)
Cefaclor 0.72 (0.05, 10.32)
IV Tetracycline 0.02 (0.00, 0.15)
IV Cefuroxime 0.09 (0.01, 0.95)
IM Teicoplanin 0.10 (0.01, 1.27)
Topical Amoxicillin 0.33 (0.03, 3.48)
Antiseptic Rinse 0.24 (0.03, 1.90)
IM Pen. OR IV Erythro. OR Oral OR IV Amox. 0.30 (0.03, 3.06)
.1 1 10
Favors Prophylaxis Favors No Prophylaxis

Table 31 Conversion of Odds Ratio from Figure 37 to Number Needed to Treat (NNT)
Treatment NNT
Amoxicillin 1.8
Penicillin 2.5
Erythromycin 5.0
Clindamycin 3.0
Josamycin 14.0
Moxifloxacin 1.9
Cefaclor 9.3
IV Tetracycline 1.5
IV Cefuroxime 2.1
IM Teicoplanin 2.2
Topical Amoxicillin 4.0
Antiseptic Rinse 3.2
IM Pen. OR IV Erythro. OR Oral OR IV Amox. 3.7

Table 32 Network Meta-Analysis Rankings of Antibiotic Prophylaxes for the Prevention of Dental-related Bacteremia
Rank
1 14
Prophylaxis (Best) 2 3 4 5 6 7 8 9 10 11 12 13 (Worst)
Placebo/No
Treatment 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.1% 0.5% 2.8% 10.8% 27.3% 38.4% 20.2%
Amoxicillin 1.7% 14.2% 28.9% 28.5% 16.4% 6.8% 2.5% 0.7% 0.2% 0.0% 0.0% 0.0% 0.0% 0.0%
Penicillin 0.3% 1.9% 4.2% 8.1% 13.4% 17.3% 16.8% 14.1% 10.4% 6.8% 4.0% 1.7% 0.6% 0.2%
Erythromycin 0.0% 0.1% 0.3% 0.6% 1.5% 3.3% 6.3% 10.3% 15.6% 20.3% 20.4% 13.2% 6.1% 2.0%
Clindamycin 0.0% 0.4% 1.5% 3.7% 8.1% 12.9% 16.7% 18.3% 16.7% 11.6% 6.3% 2.6% 0.9% 0.3%
Josamycin 0.1% 0.3% 0.6% 1.0% 1.5% 2.3% 3.2% 4.4% 6.0% 8.6% 11.5% 14.5% 17.4% 28.5%
Moxifloxacin 8.2% 22.1% 18.9% 15.4% 11.8% 8.5% 5.8% 3.7% 2.3% 1.5% 0.9% 0.5% 0.2% 0.1%
Cefaclor 0.5% 1.4% 1.7% 2.1% 2.8% 3.7% 4.5% 5.5% 6.7% 8.1% 9.9% 11.1% 13.8% 28.0%
IV Tetracycline 67.7% 16.2% 6.5% 3.6% 2.3% 1.4% 0.9% 0.6% 0.3% 0.2% 0.1% 0.1% 0.0% 0.0%
IV Cefuroxime 8.8% 18.3% 13.0% 11.2% 10.9% 9.0% 7.3% 6.0% 4.7% 3.9% 2.9% 1.9% 1.3% 0.9%
IM Teicoplanin 9.3% 15.5% 11.6% 10.3% 10.0% 8.6% 7.4% 6.6% 5.7% 4.7% 3.9% 2.8% 2.0% 1.6%
Topical
Amoxicillin 1.1% 3.0% 3.8% 4.7% 6.3% 7.6% 8.2% 8.9% 9.6% 10.4% 10.3% 9.3% 8.1% 8.6%
Antiseptic Rinse 1.1% 3.4% 4.6% 5.8% 8.2% 10.3% 11.3% 11.1% 11.0% 10.4% 8.8% 6.3% 4.3% 3.2%
IM Pen. OR IV
Erythro. OR Oral
OR IV Amox. 1.1% 3.1% 4.2% 4.9% 6.8% 8.2% 9.1% 9.6% 10.2% 10.7% 10.4% 8.7% 6.8% 6.5%

RECOMMENDATION 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

Description: Evidence from a single low quality study or conflicting findings that do not allow a
recommendation for or against the intervention. An Inconclusive recommendation means that
there is a lack of compelling evidence resulting in an unclear balance between benefits and
potential harm.
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.
RATIONALE
There is high quality evidence that demonstrates the occurrence of bacteremias with dental
procedures. However, there is no evidence to demonstrate a direct link between dental procedure
associated bacteremia and infection of prosthetic joints or other orthopaedic implants.
There is conflicting evidence regarding the effect of antimicrobial mouth rinse on the incidence
of bacteremia associated dental procedures. One high quality study reports no difference in the
incidence of bacteremia following antimicrobial mouth rinsing in patients undergoing dental
extractions. Conversely, numerous studies suggest that topical antimicrobial prophylaxis
decreases the incidence of dental procedure associated bacteremia. However, there is no
evidence that application of antimicrobial mouth rinses before dental procedures prevents
infection of prosthetic joints or other orthopaedic implants.
FINDINGS
As illustrated in Figure 1 there is varying quality of evidence that explains the relationship
between dental procedures and orthopaedic implant infection. Only one moderate quality study
of direct evidence was considered for this recommendation. The results of this study conclude
that dental procedures are not risk factors for subsequent orthopaedic implant infection.
However, multiple high quality studies of indirect evidence link oral procedures to bacteremia
(see Figure 2 - Figure 5). Furthermore, multiple studies of indirect evidence of moderate strength
suggest that topical antimicrobial prophylaxis prevents post-dental procedure bacteremia. Details
of our analysis on topical antimicrobial prophylaxis are presented in the results section below.

Of the 12 studies included for this recommendation, 1 was of high quality and moderate
applicability, 7 were of moderate quality and moderate applicability, and 4 were of low quality
and moderate applicability. For details see Table 69 and Table 87 of Appendix XII.

RESULTS
Twelve studies were included that investigated the efficacy of topical antimicrobials for
prevention of dental procedure related bacteremia. Direct and indirect comparisons were drawn
from network meta-analysis as diagramed in Figure 38. Table 33, Table 34, and Table 35
summarize the results of these comparisons. Figure 39 and Figure 40 graphically depict the
direct and indirect topical antimicrobial comparisons vs. no treatment. Odds ratios were
converted to number needed to treat (NNT) for a more clinically meaningful interpretation (see
Table 36). Rankings of the topicals are presented in Table 37. These rankings do not indicate
statistical significance.
The overall network model was consistent. See Table 60 in Appendix XI. Goodness-of-fit
statistics are also presented in Appendix XI (see
Table 61). These results suggest that our model fits the available data. Individual study results
can be found in Table 25. Individual study results that could not be meta-analyzed can be found
in Table 68 in Appendix XI.
Figure 38 Network Diagram of Topical Antimicrobial Prophylaxes for the Prevention of

Chlorhex- 1 2
Saline
idine
Rinse
Rinse
1
Placebo
Rinse
Phenolated 1
Rinse
2 1
Sodium 3
Perborate 2
2 – Ascorbic
Chloramine Acid Rinse
2
T Rinse
1
1 1
1 Povidone- 1 Isolation 1
Iodine + Iodine
1 Rinse Rinse
Lugol’s
1 No 1
Solution 1
Treatment 1 1
Rinse
2
Isolation +
Operative 1 Chlorhex-
Hydrogen Field idine
Peroxide Isolation Rinse
Rinse

Circles denote the treatments studied. Lines between circles denote treatment comparisons that
are addressed by direct evidence. The numbers on these lines show the number of trials that
compared the two treatments denoted in the circles.
Table 33 Direct Comparisons of Topical Antimicrobial Prophylaxes for the Prevention of

Comparison Studies Odds Ratio (95% CI)
Saline Rinse vs. No Treatment 2 0.778* (0.249, 2.429)
Chlorhexidine Rinse vs. No Treatment 2 0.219 (0.08, 0.597)
Povidone-Iodine Rinse vs. No Treatment 1 0.231 (0.061, 0.869)
Chloramine T Rinse/Brush vs. No Treatment 1 0.176 (0.053, 0.586)
Lugol's Solution Rinse vs. No Treatment 1 0.762 (0.179, 3.249)
Hydrogen Peroxide Rinse vs. No Treatment 2 0.379 (0.192, 0.748)
Sodium Perborate-Ascorbic Acid Rinse vs. No Treatment 1 0.211 (0.093, 0.479)
Phenolated Rinse vs. No Treatment 2 0.192* (0.067, 0.545)
Chlorhexidine Rinse vs. Saline Rinse 1 0.083 (0.019, 0.37)
Povidone-Iodine Rinse vs. Saline Rinse 1 0.167 (0.041, 0.686)
Sodium Perborate-Ascorbic Acid Rinse vs. Saline Rinse 1 0.146 (0.05, 0.43)
Phenolated Rinse vs. Saline Rinse 1 0.253 (0.115, 0.557)
Povidone-Iodine Rinse vs. Chlorhexidine Rinse 3 0.812 (0.352, 1.872)
Hydrogen Peroxide Rinse vs. Chlorhexidine Rinse 1 1.5 (0.429, 5.248)
Chlorhexidine Rinse vs. Placebo Rinse 2 0.623 (0.286, 1.356)
Hydrogen Peroxide Rinse vs. Povidone-Iodine Rinse 1 1.857 (0.522, 6.612)
Povidone-Iodine Rinse vs. Placebo Rinse 2 0.325 (0.162, 0.651)
Lugol's Solution Rinse vs. Chloramine T Rinse/Brush 1 4.333 (1.405, 13.36)
Operative Field Isolation vs. Organic Iodine Rinse 1 0.420 (0.166, 1.062)
Isolation + Iodine Rinse vs. Organic Iodine Rinse 1 0.373 (0.146, 0.953)
Isolation + Chlorhexidine Rinse vs. Organic Iodine Rinse 1 0.122 (0.039, 0.382)
Isolation + Iodine Rinse vs. Operative Field Isolation 1 0.887 (0.340, 2.314)
Isolation + Chlorhexidine Rinse vs. Operative Field Isolation 1 0.291 (0.091, 0.925)
Isolation + Chlorhexidine Rinse vs. Isolation + Iodine Rinse 1 0.328 (0.102, 1.050)
*Heterogeneity (I2 >50%)

Figure 39 Forest Plot of Direct Comparisons of Topical Antimicrobials vs. No Treatment
for the Prevention of Dental-related Bacteremia

Table 34 Indirect (Network) Comparisons of Topical Antimicrobial Prophylaxes for the
Prevention of Dental-related Bacteremia
Comparison Odds Ratio (95% CI)
Saline Rinse vs. No Treatment 0.960 (0.402, 2.447)
Chlorhexidine Rinse vs. No Treatment 0.170 (0.059, 0.459)
Povidone-Iodine Rinse vs. No Treatment 0.143 (0.049, 0.412)
Chloramine T Rinse/Brush vs. No Treatment 0.158 (0.025, 0.891)
Lugol's Solution Rinse vs. No Treatment 0.740 (0.100, 5.269)
Hydrogen Peroxide Rinse vs. No Treatment 0.331 (0.108, 0.989)
Sodium Perborate-Ascorbic Acid Rinse vs. No Treatment 0.174 (0.041, 0.710)
Phenolated Rinse vs. No Treatment 0.216 (0.078, 0.612)
Placebo Rinse vs. No Treatment 0.400 (0.107, 1.485)
Operative Field Isolation vs. No Treatment 0.058 (0.008, 0.377)
Isolation + Iodine Rinse vs. No Treatment 0.051 (0.007, 0.331)
Isolation + Chlorhexidine Rinse vs. No Treatment 0.015 (0.002, 0.113)
Chlorhexidine Rinse vs. Saline Rinse 0.177 (0.051, 0.548)
Povidone-Iodine Rinse vs. Saline Rinse 0.149 (0.043, 0.475)
Chloramine T Rinse/Brush vs. Saline Rinse 0.165 (0.020, 1.147)
Lugol's Solution Rinse vs. Saline Rinse 0.771 (0.085, 6.586)
Hydrogen Peroxide Rinse vs. Saline Rinse 0.345 (0.084, 1.290)
Sodium Perborate-Ascorbic Acid Rinse vs. Saline Rinse 0.181 (0.040, 0.768)
Phenolated Rinse vs. Saline Rinse 0.225 (0.067, 0.718)
Placebo Rinse vs. Saline Rinse 0.417 (0.095, 1.714)
Operative Field Isolation vs. Saline Rinse 0.061 (0.008, 0.414)
Isolation + Iodine Rinse vs. Saline Rinse 0.054 (0.007, 0.364)
Isolation + Chlorhexidine Rinse vs. Saline Rinse 0.016 (0.001, 0.125)
Povidone-Iodine Rinse vs. Chlorhexidine Rinse 0.842 (0.349, 2.097)
Chloramine T Rinse/Brush vs. Chlorhexidine Rinse 0.932 (0.117, 7.113)
Lugol's Solution Rinse vs. Chlorhexidine Rinse 4.340 (0.474, 40.44)
Hydrogen Peroxide Rinse vs. Chlorhexidine Rinse 1.946 (0.553, 7.127)
Sodium Perborate-Ascorbic Acid Rinse vs. Chlorhexidine Rinse 1.023 (0.190, 5.708)
Phenolated Rinse vs. Chlorhexidine Rinse 1.267 (0.324, 5.328)
Placebo Rinse vs. Chlorhexidine Rinse 2.348 (0.854, 6.862)
Operative Field Isolation vs. Chlorhexidine Rinse 0.344 (0.057, 2.095)
Isolation + Iodine Rinse vs. Chlorhexidine Rinse 0.304 (0.050, 1.870)
Isolation + Chlorhexidine Rinse vs. Chlorhexidine Rinse 0.093 (0.013, 0.635)
Chloramine T Rinse/Brush vs. Povidone-Iodine Rinse 1.106 (0.136, 8.524)
Lugol's Solution Rinse vs. Povidone-Iodine Rinse 5.150 (0.552, 48.47)
Hydrogen Peroxide Rinse vs. Povidone-Iodine Rinse 2.308 (0.625, 8.364)
Sodium Perborate-Ascorbic Acid Rinse vs. Povidone-Iodine Rinse 1.214 (0.219, 6.739)
Phenolated Rinse vs. Povidone-Iodine Rinse 1.504 (0.370, 6.328)
Placebo Rinse vs. Povidone-Iodine Rinse 2.787 (1.037, 7.675)

Comparison Odds Ratio (95% CI)
Operative Field Isolation vs. Povidone-Iodine Rinse 0.409 (0.084, 1.962)
Isolation + Iodine Rinse vs. Povidone-Iodine Rinse 0.361 (0.074, 1.709)
Isolation + Chlorhexidine Rinse vs. Povidone-Iodine Rinse 0.110 (0.019, 0.592)
Lugol's Solution Rinse vs. Chloramine T Rinse/Brush 4.655 (0.872, 26.95)
Hydrogen Peroxide Rinse vs. Chloramine T Rinse/Brush 2.087 (0.261, 17.56)
Sodium Perborate-Ascorbic Acid Rinse vs. Chloramine T Rinse/Brush 1.098 (0.114, 11.16)
Phenolated Rinse vs. Chloramine T Rinse/Brush 1.360 (0.182, 11.11)
Placebo Rinse vs. Chloramine T Rinse/Brush 2.519 (0.287, 23.78)
Operative Field Isolation vs. Chloramine T Rinse/Brush 0.369 (0.027, 4.997)
Isolation + Iodine Rinse vs. Chloramine T Rinse/Brush 0.326 (0.024, 4.499)
Isolation + Chlorhexidine Rinse vs. Chloramine T Rinse/Brush 0.100 (0.006, 1.473)
Hydrogen Peroxide Rinse vs. Lugol's Solution Rinse 0.448 (0.047, 4.263)
Sodium Perborate-Ascorbic Acid Rinse vs. Lugol's Solution Rinse 0.235 (0.020, 2.740)
Phenolated Rinse vs. Lugol's Solution Rinse 0.292 (0.031, 2.784)
Placebo Rinse vs. Lugol's Solution Rinse 0.540 (0.051, 5.766)
Operative Field Isolation vs. Lugol's Solution Rinse 0.079 (0.005, 1.206)
Isolation + Iodine Rinse vs. Lugol's Solution Rinse 0.070 (0.004, 1.070)
Isolation + Chlorhexidine Rinse vs. Lugol's Solution Rinse 0.021 (0.001, 0.358)
Sodium Perborate-Ascorbic Acid Rinse vs. Hydrogen Peroxide Rinse 0.526 (0.090, 3.089)
Phenolated Rinse vs. Hydrogen Peroxide Rinse 0.651 (0.150, 2.980)
Placebo Rinse vs. Hydrogen Peroxide Rinse 1.206 (0.267, 5.595)
Operative Field Isolation vs. Hydrogen Peroxide Rinse 0.177 (0.023, 1.340)
Isolation + Iodine Rinse vs. Hydrogen Peroxide Rinse 0.156 (0.020, 1.188)
Isolation + Chlorhexidine Rinse vs. Hydrogen Peroxide Rinse 0.048 (0.005, 0.405)
Phenolated Rinse vs. Sodium Perborate-Ascorbic Acid Rinse 1.238 (0.231, 6.868)
Placebo Rinse vs. Sodium Perborate-Ascorbic Acid Rinse 2.293 (0.346, 15.19)
Operative Field Isolation vs. Sodium Perborate-Ascorbic Acid Rinse 0.336 (0.032, 3.340)
Isolation + Iodine Rinse vs. Sodium Perborate-Ascorbic Acid Rinse 0.297 (0.029, 2.956)
Isolation + Chlorhexidine Rinse vs. Sodium Perborate-Ascorbic Acid
Rinse 0.091 (0.007, 0.987)
Placebo Rinse vs. Phenolated Rinse 1.852 (0.359, 9.290)
Operative Field Isolation vs. Phenolated Rinse 0.271 (0.032, 2.172)
Isolation + Iodine Rinse vs. Phenolated Rinse 0.240 (0.028, 1.919)
Isolation + Chlorhexidine Rinse vs. Phenolated Rinse 0.073 (0.007, 0.648)
Operative Field Isolation vs. Placebo Rinse 0.146 (0.022, 0.921)
Isolation + Iodine Rinse vs. Placebo Rinse 0.129 (0.019, 0.819)
Isolation + Chlorhexidine Rinse vs. Placebo Rinse 0.039 (0.005, 0.277)
Isolation + Iodine Rinse vs. Operative Field Isolation 0.883 (0.181, 4.271)
Isolation + Chlorhexidine Rinse vs. Operative Field Isolation 0.271 (0.046, 1.478)
Isolation + Chlorhexidine Rinse vs. Isolation + Iodine Rinse 0.306 (0.052, 1.677)

Table 35 Indirect (Network) Significant Comparisons of Topical Antimicrobial
Prophylaxes for the Prevention of Dental-related Bacteremia
Comparison
Chlorhexidine Rinse vs. No Treatment
Povidone-Iodine Rinse vs. No Treatment
Chloramine T Rinse/Brush vs. No Treatment
Hydrogen Peroxide Rinse vs. No Treatment
Sodium Perborate-Ascorbic Acid Rinse vs. No Treatment
Phenolated Rinse vs. No Treatment
Operative Field Isolation vs. No Treatment
Isolation + Iodine Rinse vs. No Treatment
Isolation + Chlorhexidine Rinse vs. No Treatment
Chlorhexidine Rinse vs. Saline Rinse
Povidone-Iodine Rinse vs. Saline Rinse
Sodium Perborate-Ascorbic Acid Rinse vs. Saline Rinse
Phenolated Rinse vs. Saline Rinse
Operative Field Isolation vs. Saline Rinse
Isolation + Iodine Rinse vs. Saline Rinse
Isolation + Chlorhexidine Rinse vs. Saline Rinse
Isolation + Chlorhexidine Rinse vs. Chlorhexidine Rinse
Povidone-Iodine Rinse vs. Placebo Rinse
Isolation + Chlorhexidine Rinse vs. Povidone-Iodine Rinse
Isolation + Chlorhexidine Rinse vs. Lugol's Solution Rinse
Isolation + Chlorhexidine Rinse vs. Hydrogen Peroxide Rinse
Isolation + Chlorhexidine Rinse vs. Sodium Perborate-Ascorbic Acid Rinse
Isolation + Chlorhexidine Rinse vs. Phenolated Rinse
Operative Field Isolation vs. Placebo Rinse
Isolation + Iodine Rinse vs. Placebo Rinse
Isolation + Chlorhexidine Rinse vs. Placebo Rinse

Figure 40 Forest Plot of Indirect (Network) Comparisons of Topical Antimicrobials vs. No
Treatment for the Prevention of Dental-related Bacteremia
Odds
Treatment Ratio (95% CI)
Saline Rinse 0.96 (0.40, 2.45)
Chlorhexidine Rinse 0.17 (0.06, 0.46)
Povidone-Iodine Rinse 0.14 (0.05, 0.41)
Chloramine T Rinse/Brush 0.16 (0.03, 0.89)
Lugol's Solution Rinse 0.74 (0.10, 5.27)
Hydrogen Peroxide Rinse 0.33 (0.11, 0.99)
Sodium Perborate-Ascorbic Acid Rinse 0.17 (0.04, 0.71)
Phenolated Rinse 0.22 (0.08, 0.61)
Placebo Rinse 0.40 (0.11, 1.49)
Operative Field Isolation 0.06 (0.01, 0.38)
Isolation + Iodine Rinse 0.05 (0.01, 0.33)
Isolation + Chlorhexidine Rinse 0.02 (0.00, 0.11)
.1 1 10
Favors Prophylaxis Favors No Prophylaxis

Table 36 Conversion of Odds Ratio from Figure 40 to Number Needed to Treat (NNT)
Treatment NNT
Saline Rinse 70.0
Chlorhexidine Rinse 2.5
Povidone-Iodine Rinse 2.3
Chloramine T Rinse/Brush 2.5
Lugol's Solution Rinse 11.7
Hydrogen Peroxide Rinse 3.9
Sodium Perborate-Ascorbic Acid Rinse 2.5
Phenolated Rinse 2.8
Placebo Rinse n/a
Operative Field Isolation 1.8
Isolation + Iodine Rinse 1.8
Isolation + Chlorhexidine Rinse 1.5

Table 37 Network Meta-Analysis Rankings of Topical Antimicrobial Prophylaxes for the Prevention of Dental-related
Bacteremia
Rank
1 13
Prophylaxis (Best) 2 3 4 5 6 7 8 9 10 11 12 (Worst)
None 0% 0% 0% 0% 0% 0% 0% 0% 1% 3% 20% 45% 32%
Saline Rinse 0% 0% 0% 0% 0% 0% 0% 1% 2% 7% 25% 34% 31%
Chlorhexidine
Rinse 0% 1% 4% 11% 20% 23% 19% 13% 6% 2% 0% 0% 0%
Povidone-Iodine
Rinse 0% 1% 4% 25% 27% 20% 13% 7% 3% 1% 0% 0% 0%
Chloramine T
Rinse/Brush 3% 8% 9% 16% 11% 10% 10% 11% 10% 8% 2% 1% 0%
Lugol's Solution
Rinse 0% 0% 1% 1% 2% 2% 3% 5% 8% 13% 21% 11% 32%
Hydrogen
Peroxide Rinse 0% 0% 1% 2% 3% 6% 10% 16% 25% 23% 10% 2% 1%
Sodium Perborate-
Ascorbic Acid
Rinse 1% 5% 7% 14% 13% 13% 13% 12% 10% 6% 3% 1% 0%
Phenolated Rinse 0% 2% 3% 8% 11% 15% 18% 18% 14% 8% 3% 0% 0%
Placebo Rinse 0% 0% 0% 1% 1% 4% 8% 13% 21% 28% 16% 5% 3%
Operative Field
Isolation 4% 31% 37% 12% 6% 4% 2% 2% 1% 1% 0% 0% 0%
Isolation + Iodine
Rinse 6% 41% 31% 10% 4% 3% 2% 1% 1% 0% 0% 0% 0%
Isolation +
Chlorhexidine
Rinse 84% 11% 3% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0%

RECOMMENDATION 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
Description: The supporting evidence is lacking and requires the work group to make a
recommendation. A Consensus recommendation means that expert opinion supports the
guideline recommendation even though there is no available empirical evidence that meets the
inclusion criteria.
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.
RATIONALE
The lack of evidence relating oral bacteremias to prosthetic joint or other orthopaedic implant
infections is the basis for the consensus rationale for this recommendation.
Oral hygiene measures are low cost, provide potential benefit, are consistent with current
practice, and are in accordance with good oral health.
There is evidence of the relationship of oral microflora to bacteremia. This bacteremia may be
associated with poor oral hygiene. This implies that improvement of oral hygiene (or
maintenance of good oral hygiene) may be beneficial in reducing bacteremias.
FINDINGS
No direct evidence was found in support of Recommendation 3. However, several prognostic
studies of indirect evidence are included that explore whether or not oral health status can predict
development of bacteremia after dental procedures. These low strength studies address oral
health indicators as potential risk factors for developing bacteremia as a result of undergoing a
dental procedure. The results of these studies are inconsistent and summarized in the results
section below. See Table 38 for a summary of study results and Table 39 - Table 47 for more
detail. By optimizing oral health, one could eliminate these potential risk factors and therefore
reduce their risk of developing a dental procedure related bacteremia.


Table 38 Summary of Oral Health Related Risk Factor (Proportion of studies that reported significant results)
Brushing Chewing Dental Inter- Intubation Oral Periodontic Restorative Tooth
Cleaning
Risk Factor Results (%Significant, n/N)
# Teeth Present 0%, 0/1 0%, 0/1
Abscess 0%, 0/1 0%, 0/2
Apical Lucency 0%, 0/1 0%, 0/1
Calculus 100%, 1/1 0%, 1/1
Index/Score
Caries 0%, 0/1 0%, 0/1 0%, 0/1
Caries Depth 0%, 0/1 0%, 0/1 0%, 0/1
Clinical 0%, 0/1
Attachment Loss
Gingival 25%, 1/4 100%, 1/1 0%, 0/1 50%, 1/2 100%, 1/1 67%, 2/3
Index/Score
Gingival Size 0%, 0/1
Gingivitis 0%, 0/1 0%, 0/1 0%, 0/1
Infected Tooth 100%,
1/1
Odontogenic 0%, 0/1
Disease
Oral Health 0%, 0/1 0%, 0/1 50%, 1/2
Status
Periodontal 0%, 0/1 0%, 0/1
Diagnosis
Periodontitis 0%, 0/1 0%, 0/1 100%, 1/1 0%, 0/1 50%, 1/2 0%, 0/1
Plaque 67%, 2/3 50%, 1/2 0%, 0/1 0%, 0/1 0%, 0/3
Index/Score
Probing Depth 0%, 0/2 0%, 0/1 0%, 0/1 33%, 1/3
Probing Depth 0%, 0/1 100%, 1/1 0%, 0/1
Mean
Radiolucency 0%, 0/1
Recession 0%, 0/1

Brushing Chewing Dental Inter- Intubation Oral Periodontic Restorative Tooth
Cleaning
Suppuration 0%, 0/1
Swelling 0%, 0/1
Tooth Mobility 0%, 0/1 0%, 0/1

Table 39 Oral Health Related Risk Factors for Brushing Bacteremia
Bacteremia p<0.01 @ 30s
Ashare Linear (Bacterial Load @ & 5m, NS @
2009 Low 48 regression 30s, 5m, 15m) Plaque Index 15m
Bhanji logistic OR 1.05,
2002 Low 50 regression Bacteremia Plaque Score p=0.44
Bacteremia
(Infective
Lockhart logistic Endocarditis Mean plaque OR 2.53
2009 Low 98 regression related bacteria) score p=.010
Bacteremia
(Infective
Lockhart logistic Endocarditis Plaque score OR 3.78
2009 Low 98 regression related bacteria) ≥2 p=.008
Bacteremia
Ashare Linear (Bacterial Load @ Gingival NS for all
2009 Low 48 regression 30s, 5m, 15m) Index time points
Bhanji Gingival
2002 Low 50 chi square Bacteremia Score p=0.96
Bacteremia
(Infective
Lockhart logistic Endocarditis Mean gingival OR 1.62
Bacteremia
(Infective
Lockhart logistic Endocarditis Gingival OR 1.61
2009 Low 98 regression related bacteria) score ≥ 2 p=.335
Silver Gingival
1977 Low 96 Critical ratio test Bacteremia Index p<.01
Forner
2006 Low 20 Fishers exact test Bacteremia Gingivitis NS
Forner
2006 Low 20 Fishers exact test Bacteremia Periodontitis NS
Bacteremia
(Infective
Lockhart logistic Endocarditis Mean calculus OR 1.77
Bacteremia
(Infective
Lockhart logistic Endocarditis Calculus OR 4.43
2009 Low 98 regression related bacteria) score ≥ 2 p=.004
Bacteremia
(Infective
Lockhart logistic Endocarditis Bleeding with OR 0.89
2009 Low 98 regression related bacteria) toothbrushing p=.810

Bacteremia
(Infective Bleeding type
Lockhart logistic Endocarditis with OR 7.96
2009 Low 98 regression related bacteria) toothbrushing p=.015
Bacteremia
(Infective
Lockhart logistic Endocarditis Mean probing OR 1.02
2009 Low 98 regression related bacteria) depth p=.918
Bacteremia
(Infective
Lockhart logistic Endocarditis Tooth OR 1.93
2009 Low 98 regression related bacteria) mobility score p=.200
Bacteremia
(Infective
Lockhart logistic Endocarditis OR 4.40
2009 Low 98 regression related bacteria) Dental caries p=.165
Bacteremia
(Infective
Lockhart logistic Endocarditis Depth of OR 0.43
2009 Low 98 regression related bacteria) dental caries p=.155
Bacteremia
(Infective
Lockhart logistic Endocarditis Apical OR 2.37
2009 Low 98 regression related bacteria) lucency p=.086
Bacteremia
(Infective Apical
Lockhart logistic Endocarditis lucency size OR 0.87
2009 Low 98 regression related bacteria) (mm) p=.647
Table 40 Oral Health Related Risk Factors for Chewing Bacteremia

Forner
2006 Very Low 20 Fisher's exact test Bacteremia Periodontitis NS
Forner
2006 Very Low 20 Fisher's exact test Bacteremia Gingivitis NS
Table 41 Oral Health Related Risk Factors for Dental Prophylaxis Bacteremia
Cherry Logistic
2007 Low 60 regression Bacteremia Plaque Index NS
Spearman's
Forner correlation Bacteremia
2006 Low 20 coefficients (magnitude) Plaque Index 0.41 p=.0117
Modified
papilla,
margin,
Cherry Logistic attached
2007 Low 60 regression Bacteremia gingiva index NS

Cherry Logistic
2007 Low 60 regression Bacteremia Probing depth NS
Cherry Logistic
2007 Low 60 regression Bacteremia Recession NS
Cherry Logistic Bleeding on
2007 Low 60 regression Bacteremia scaling NS
Forner
2006 Low 20 Fishers exact test Bacteremia Periodontitis p<.001
Spearman's
Forner correlation Bacteremia Periodontal
2006 Low 20 coefficients (magnitude) diagnosis NS
Forner
2006 Low 20 Fishers exact test Bacteremia Gingivitis NS
Spearman's
Forner correlation Bacteremia Gingival
2006 Low 20 coefficients (magnitude) Index 0.53 p<.0001
Spearman's
Forner correlation Bacteremia Bleeding on
2006 Low 20 coefficients (magnitude) probing 0.45 p=.0089
Spearman's Probing
Forner correlation Bacteremia pocket depth
2006 Low 20 coefficients (magnitude) >5 NS
Spearman's
Forner correlation Bacteremia Pocket sum
2006 Low 20 coefficients (magnitude) score NS
Table 42 Oral Health Related Risk Factors for Inter-dental Cleaning Bacteremia
Spearman's
Crasta correlation
2009 Low 60 coefficients Bacteremia Periodontitis 0.17 p=.2
Spearman's
Crasta correlation Gingival
2009 Low 60 coefficients Bacteremia Index 0.22 p=.09
Spearman's
Crasta correlation
2009 Low 60 coefficients Bacteremia Plaque Index 0.07 p=.6
Spearman's % of sites
Crasta correlation bleeding on
2009 Low 60 coefficients Bacteremia flossing 0.17 p=.2
Spearman's # sites
2009 Low 60 coefficients Bacteremia flossing 0.17 p=.2
Spearman's % of sites
2009 Low 60 coefficients Bacteremia probing 0.16 p=.2

Spearman's
Crasta correlation
2009 Low 60 coefficients Bacteremia Pocket depth 0.09 p=.5
Spearman's Clinical
Crasta correlation attachment
2009 Low 60 coefficients Bacteremia loss 0.06 p=.6
Spearman's
Crasta correlation Self-reported
2009 Low 60 coefficients Bacteremia daily flossing −0.12 p=.4
Table 43 Oral Health Related Risk Factors for Intubation Bacteremia

Valdes Logistic Oral health
2008 Low 110 regression Bacteremia status NS
Table 44 Oral Health Related Risk Factors for Oral Surgery Bacteremia
Roberts 1.878
1998 Low 154 chi-square Bacteremia Abscess p=.1706
Pearson
Roberts correlation
1998 Low 154 coefficient Bacteremia Age 0.29
Tomas
2008 Low 100 not reported Bacteremia Age NS
Scheffe's
Roberts multiple
1998 Low 154 comparison Bacteremia Plaque Index p=.47
Scheffe's
Roberts multiple Gingival
1998 Low 154 comparison Bacteremia Index p<.03
Takai Gingival
2005 Low 237 chi-square Bacteremia Index NS
Scheffe's
Roberts multiple Bleeding
1998 Low 154 comparison Bacteremia Index p<.04
Oral hygiene
Takai index
2005 Low 237 chi-square Bacteremia simplified NS
Takai
2005 Low 237 chi-square Bacteremia # teeth present NS
Takai
2005 Low 237 chi-square Bacteremia Blood loss NS
Infection in
extracted tooth
(periodontitis,
periapical
Takai infection, and
2005 Low 237 chi-square Bacteremia pericoronitis) p<.01

Table 45 Oral Health Related Risk Factors for Periodontic Bacteremia
Daly Periodontitis
1997 Low 30 chi-square Bacteremia severity p=.9
OR 5.993
Daly logistic CI=1.081-
2001 Low 40 regression Bacteremia Periodontitis 33.215
Daly Bleeding on
1997 Low 30 t-test Bacteremia probing p=.3
OR 1.025
Daly logistic Bleeding on CI=1.004-
2001 Low 40 regression Bacteremia probing 1.047
OR 1.0
Daly logistic CI=.845-
2001 Low 40 regression Bacteremia # of teeth 1.185
OR 1.006
Daly logistic Total probing CI=.999-
2001 Low 40 regression Bacteremia depth 1.013
OR 3.154
Daly logistic CI=.603-
2001 Low 40 regression Bacteremia Plaque index 16.514
Mean probing OR 1.444
Daly logistic depth per CI=.1.055-
2001 Low 40 regression Bacteremia tooth 1.977
Table 46 Oral Health Related Risk Factors for Restorative Bacteremia

Brennan chi-square or Gingival
2007 Very Low 51 fisher's exact Bacteremia Score (0-3) p=.01
Brennan chi-square or Gingival Size
2007 Very Low 51 fisher's exact Bacteremia (0-3) NS
Periodontal
disease with
Brennan chi-square or probing
2007 Very Low 51 fisher's exact Bacteremia >3mm NS
Brennan chi-square or Mixed
2007 Very Low 51 fisher's exact Bacteremia Dentition p=.08
Brennan chi-square or
2007 Very Low 51 fisher's exact Bacteremia Caries Present NS
Brennan chi-square or Depth of
2007 Very Low 51 fisher's exact Bacteremia caries (0-3) NS
Brennan chi-square or Periapical
2007 Very Low 51 fisher's exact Bacteremia radiolucency NS
Size
Brennan chi-square or radiolucency
2007 Very Low 51 fisher's exact Bacteremia (mm) NS
2007 Very Low 51 fisher's exact Bacteremia Swelling NS

2007 Very Low 51 fisher's exact Bacteremia Suppuration NS
Table 47 Oral Health Related Risk Factors for Extraction Bacteremia

logistic OR 3.704
Barbosa regression Oral health (1.929-
2010 Low 210 (univariate) Bacteremia 30s status 7.109)
logistic OR 2.047
Barbosa regression Oral health (1.138-
2010 Low 210 (univariate) Bacteremia 15m status 3.683)
Wahlmann logistic
1999 Low 59 regression Bacteremia Oral Hygiene NS
Wahlmann logistic Periodontal
1999 Low 59 regression Bacteremia status NS
Coulter
1990 Low 58 chi-square Bacteremia Plaque Index NS
Lockhart logistic Mean plaque OR 0.74
2009 Low 96 regression Bacteremia score p=.236
Lockhart logistic OR 0.90
2009 Low 96 regression Bacteremia Plaque score ≥ 2 p=.811
Scheffe's
Roberts multiple
1998 Low 154 comparison Bacteremia Plaque Index p=.47
Coulter
1990 Low 58 chi-square Bacteremia Gingival Index NS
Lockhart logistic Mean gingival OR 0.71
Lockhart logistic Gingival score OR 0.76
2009 Low 96 regression Bacteremia ≥2 p=.518
Scheffe's
Roberts multiple
1998 Low 154 comparison Bacteremia Gingival Index p<.03
Coulter
1990 Low 58 Fisher's Bacteremia Abscess p=0.2088
Roberts 1.878
1998 Low 154 chi-square Bacteremia Abscess p=.1706
Lockhart chi-square or Odontogenic
1996 Low 70 Fisher's exact Bacteremia disease severity NS
Lockhart logistic Mean calculus OR 0.93
Lockhart logistic Calculus score OR 0.82
2009 Low 96 regression Bacteremia ≥2 p=.715
Lockhart logistic Bleeding with
2009 Low 96 regression Bacteremia toothbrushing NA
Bleeding type
Lockhart logistic with
2009 Low 96 regression Bacteremia toothbrushing NA

Okabe 1995 Low 183 Mann-Whitney Bacteremia Blood loss (ml) 3997.5 p<.05
Scheffe's
Roberts multiple
1998 Low 154 comparison Bacteremia Bleeding Index p<.04
Lockhart logistic Mean probing OR 0.95
2009 Low 96 regression Bacteremia depth p=.735
Lockhart logistic Tooth mobility OR 1.01
2009 Low 96 regression Bacteremia Dental caries p=.452
Lockhart logistic Depth of dental OR 0.21
2009 Low 96 regression Bacteremia caries p=.156
2009 Low 96 regression Bacteremia Apical lucency p=.724
Lockhart logistic Apical lucency OR 1.00
2009 Low 96 regression Bacteremia size (mm) p=.995

FUTURE RESEARCH
The grades of recommendation in this clinical practice guideline are “limited” at best due to the
lack of evidence in some cases and conflicting evidence in others. Only one study that met the
inclusion criteria attempted to define the relationship, or lack thereof, between dental procedures
and subsequent orthopaedic implant infections and preventive effect of antibiotic prophylaxis.
Relying on evidence that does not directly address this relationship to inform clinical practice
assumes that bacteremia is an appropriate surrogate outcome for prosthetic joint or other
orthopaedic implant associated infection. Additional research is necessary to assess the pros and
cons of providing antimicrobial prophylaxis for this study population and definitively determine
if there is an association between dental procedures and orthopaedic implant infections.
Specifically:
 Prospective, controlled (ideally randomized), adequately powered trials investigating the

effect of prophylactic interventions with the primary outcome of implant infection.
 Research investigating the relationship between bacteremias and orthopaedic implant
infection.
 Research determining if bacteremia is an appropriate surrogate outcome for orthopaedic
implant infection
 Research investigating the relationship between oral health and orthopaedic implant
infection
 Cost-benefit analysis of antimicrobial prophylaxis for patients with orthopaedic implants
undergoing dental procedures

APPENDICES

APPENDIX I
WORK GROUP

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 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 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, DSB S356
American Academy of Orthopaedic Surgeons Iowa City, IA 52242
Calin Moucha, MD
Associate Chief, Joint Replacement Surgery American Association of Hip and Knee Surgeons
Mount Sinai Medical Center David Kolessar, MD
Assistant Professor Geisinger Wyoming Valley Medical Center
Leni & Peter W. May Department of Orthopaedic 1000 East Mountain Boulevard
Surgery Valley Medical Building
Mount Sinai School of Medicine Wilkes-Barre, PA 18711
5 E. 98th Street, Box 1188, 7th Floor
New York, NY 10029 American Association of Neurological
Surgeons/Congress of Neurological Surgeons
American Academy of Orthopaedic Surgeons John E. O'Toole, MD
Richard J. O'Donnell, MD Assistant Professor of Neurosurgery
Chief, UCSF Orthopaedic Oncology Service Rush University Medical Center
UCSF Sarcoma Program 1725 W. Harrison Street, Suite 970
UCSF Helen Diller Family Comprehensive Cancer Chicago, IL 60612
Center
1600 Divisadero Street, 4th Floor American Association of Oral and
San Francisco, CA 94115 Maxillofacial Surgeons
Mark J. Steinberg DDS, MD
American Academy of Orthopaedic Surgeons & 1240 Meadow Road, Suite 300
Congress of Neurological Surgeons Northbrook, IL 60062
Paul A. Anderson, MD
Professor Department of Orthopedics &
Rehabilitation
University of Wisconsin
K4/735 600 Highland Avenue
Madison WI 53792

College of American Pathologist
Karen C. Carroll MD, FCAP
Johns Hopkins Hospital AAOS Staff
Department of Pathology-Microbiology Division Deborah S. Cummins, PhD
600 N Wolfe Street Director, Research and Scientific Affairs
Meyer B1-193 6300 N. River Road
Baltimore, MD 21287 Rosemont, IL 60018
Knee Society Sharon Song, PhD

Kevin Garvin, MD Manager, Clinical Practice Guidelines
University of Nebraska Medical Center
Creighton/Nebraska Health Fund Patrick Sluka, MPH
Department of Orthopaedic Surgery Former AAOS Lead Research Analyst
Omaha, Nebraska 68198-1080 Kevin Boyer, MPH
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]
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

APPENDIX II
CREATING PRELIMINARY RECOMMENDATIONS
In an effort to ensure the broadest literature search possible and to evaluate the many aspects
related to preventing orthopaedic implant infection in patients undergoing dental procedures, the
work group constructed a causal pathway for orthopaedic implant infection consisting of the
following factors:
 Patients
 Patient Characteristics Increasing Risk of Infection
 Prophylactic Interventions
 Effect of Intervention on:
o Bacteria/Fungi in the Mouth
o Bacteremia/Fungemia in the Blood
o Implant Infection
The factors and their components were then combined to create a series of questions from which
our literature searches were derived. The components of each factor listed above are illustrated in
the figure below. The questions for which we derived our literature searches are listed below.
Preliminary recommendations were then created based on the interventions selected for the
causal pathway. Remaining questions not directly related to an intervention (e.g. questions about
no intervention, the relationship between bacteremia and implant infection) were assessed in
order to further inform the discussion among work group members when they met at the final
recommendation meeting.

Causal Pathway
FACTORS INCREASING RISK OF INFECTION

▪ Immunocompromised (diabetes mellitus Type I and II,
autoimmune disease, organ, transplant, chemotherapy, bone
marrow transplant, HIV, steroid, obesity, hemophilia, malnutrition,
PATIENTS … tobacco exposure, alcohol, elderly, leukemia, radiation therapy,
cancer, immunomodulated therapy,)
… at risk for oral bacteremias
(i.e. everybody) ▪ Oral health status (gingivitis, periodontitis, caries,
Oral/Dental Procedure (e.g. gingival nonodontogenic infection, odontogenic infection)
manipulation or mucosal incision) ▪ Edentulous
Daily activities (naturally occurring)
(Epidemiology studies for bacteremia) ▪ History of previous implant infection
… with Bone and Joint Implant ▪ Time from implant

Prosthetic Joint Implant ▪ Multiple implants
(including silastic implants)
Massive structural allografts ▪ At risk prosthesis (revision prosthesis, prosthesis mechanically
Spinal instrumentation (e.g. rods) failed, megaprosthesis, endoprosthetic reconstruction)
Trauma device (e.g. plates, screws) ▪ Bisphosphonate therapy
Bone void fillers (e.g. allografts, bone glass,
ceramics, PMMA)
PROPHYLACTIC INTERVENTION
▪ Antibiotic (dosage, type, duration)
▪ Topical applications of
antimicrobial (Mouthwash and/or
rinse)
▪ Optimization of oral health (oral
hygiene instruction, patients and
dentists)
▪ Full mouth or partial extraction
MOUTH BLOOD
▪ Bacteria ▪ Bacteremia IMPLANT INFECTION
▪ Fungi ▪ Fungemia

Questions Derived from Causal Pathway
Relationships Between Mouth, Blood, and Implant Infection
1. What is the relationship between bacteria in the mouth and implant infection?
2. What is the relationship between fungi in the mouth and implant infection?
3. What is the relationship between bacteria in the mouth (after an oral/dental procedure) and
bacteremia?
4. What is the relationship between fungi in the mouth (after an oral/dental procedure) and
fungemia?
5. What is the relationship between bacteremia from an oral source after an oral/dental
procedure and implant infection?
6. What is the relationship between fungemia from an oral source after an oral/dental procedure
and implant infection?
Patients Without Bone and Joint Implants

7. In patients without an implant having an oral/dental procedure or undertaking daily activities
who have immunocompromising factors, what are the incidence, nature, duration, and
magnitude of bacteria in the mouth?

magnitude of fungi in the mouth?

magnitude of bacteremia in the blood?
magnitude of fungemia in the blood?
and who have Poor/Good oral health status, what are the incidence, nature, duration, and

and who have no teeth (edentulous), what are the incidence, nature, duration, and magnitude
of bacteria in the mouth?
of fungi in the mouth?
of bacteremia in the blood?
of fungemia in the blood?
and who have bisphosphonate therapy, what are the incidence, nature, duration, and
Patients With Bone and Joint Implants

23. In patients with an implant having an oral/dental procedure or undertaking daily activities
and who have immunocompromising factors, what is the effect of no intervention on the
incidence, nature, duration, and magnitude of bacteria in the mouth?
incidence, nature, duration, and magnitude of fungi in the mouth?

incidence, nature, duration, and magnitude of bacteremia?
incidence, nature, duration, and magnitude of fungemia?
incidence, nature, duration, and magnitude of implant infection?
and who have immunocompromising factors, what is the effect of antibiotic prophylaxis on
the incidence, nature, duration, and magnitude of bacteria in the mouth?
the incidence, nature, duration, and magnitude of fungi in the mouth?
the incidence, nature, duration, and magnitude of bacteremia?
the incidence, nature, duration, and magnitude of fungemia?
the incidence, nature, duration, and magnitude of implant infection?
and who have immunocompromising factors, what is the effect of topical application of
antimicrobials on the incidence, nature, duration, and magnitude of bacteria in the mouth?
antimicrobials on the incidence, nature, duration, and magnitude of fungi in the mouth?
antimicrobials on the incidence, nature, duration, and magnitude of bacteremia?
antimicrobials on the incidence, nature, duration, and magnitude of fungemia?

antimicrobials on the incidence, nature, duration, and magnitude of implant infection?
and who have immunocompromising factors, what is the effect of optimization of oral health
instructions on the incidence, nature, duration, and magnitude of bacteria in the mouth?
instructions on the incidence, nature, duration, and magnitude of fungi in the mouth?
instructions on the incidence, nature, duration, and magnitude of bacteremia?
instructions on the incidence, nature, duration, and magnitude of fungemia?
instructions on the incidence, nature, duration, and magnitude of implant infection?
and who have immunocompromising factors, what is the effect of extraction (full or partial
mouth) on the incidence, nature, duration, and magnitude of bacteria in the mouth?
mouth) on the incidence, nature, duration, and magnitude of fungi in the mouth?
mouth) on the incidence, nature, duration, and magnitude of bacteremia?
mouth) on the incidence, nature, duration, and magnitude of fungemia?
mouth) on the incidence, nature, duration, and magnitude of implant infection?
and who have Poor/Good oral health status, what is the effect of no intervention on the

and who have Poor/Good oral health status, what is the effect of antibiotic prophylaxis on the
and who have Poor/Good oral health status, what is the effect of topical application of

and who have Poor/Good oral health status, what is the effect of optimization of oral health
and who have Poor/Good oral health status, what is the effect of extraction (full or partial

and who have a history of previous implant infection, what is the effect of no intervention on
and who have history of previous implant infection, what is the effect of antibiotic
prophylaxis on the incidence, nature, duration, and magnitude of bacteria in the mouth?
prophylaxis on the incidence, nature, duration, and magnitude of fungi in the mouth?
prophylaxis on the incidence, nature, duration, and magnitude of bacteremia?
prophylaxis on the incidence, nature, duration, and magnitude of fungemia?
prophylaxis on the incidence, nature, duration, and magnitude of implant infection?
and who have history of previous implant infection, what is the effect of topical application
of antimicrobials on the incidence, nature, duration, and magnitude of bacteria in the mouth?
of antimicrobials on the incidence, nature, duration, and magnitude of fungi in the mouth?

of antimicrobials on the incidence, nature, duration, and magnitude of bacteremia?
of antimicrobials on the incidence, nature, duration, and magnitude of fungemia?
of antimicrobials on the incidence, nature, duration, and magnitude of implant infection?
and who have history of previous implant infection, what is the effect of optimization of oral
health instructions on the incidence, nature, duration, and magnitude of bacteria in the
mouth?
health instructions on the incidence, nature, duration, and magnitude of fungi in the mouth?
health instructions on the incidence, nature, duration, and magnitude of bacteremia?
health instructions on the incidence, nature, duration, and magnitude of fungemia?
health instructions on the incidence, nature, duration, and magnitude of implant infection?
and who have history of previous implant infection, what is the effect of extraction (full or
partial mouth) on the incidence, nature, duration, and magnitude of bacteria in the mouth?
partial mouth) on the incidence, nature, duration, and magnitude of fungi in the mouth?
partial mouth) on the incidence, nature, duration, and magnitude of bacteremia?
partial mouth) on the incidence, nature, duration, and magnitude of fungemia?

partial mouth) on the incidence, nature, duration, and magnitude of implant infection?
and [insert duration] since implant surgery, what is the effect of no intervention on the
and [insert duration] since implant surgery, what is the effect of antibiotic prophylaxis on the
and [insert duration] since implant surgery, what is the effect of topical application of

and [insert duration] since implant surgery, what is the effect of optimization of oral health
and [insert duration] since implant surgery, what is the effect of extraction (full or partial

and who have multiple implants, what is the effect of no intervention on the incidence,
nature, duration, and magnitude of bacteria in the mouth?
nature, duration, and magnitude of fungi in the mouth?
nature, duration, and magnitude of bacteremia?
nature, duration, and magnitude of fungemia?
nature, duration, and magnitude of implant infection?
and who have multiple implants, what is the effect of antibiotic prophylaxis on the incidence,

and who have multiple implants, what is the effect of topical application of antimicrobials on
and who have multiple implants, what is the effect of optimization of oral health instructions
on the incidence, nature, duration, and magnitude of bacteria in the mouth?
on the incidence, nature, duration, and magnitude of fungi in the mouth?
on the incidence, nature, duration, and magnitude of bacteremia?
on the incidence, nature, duration, and magnitude of fungemia?
on the incidence, nature, duration, and magnitude of implant infection?
and who have multiple implants, what is the effect of extraction (full or partial mouth) on the

and who have "at-risk" prosthesis, what is the effect of no intervention on the incidence,
and who have "at-risk" prosthesis, what is the effect of antibiotic prophylaxis on the

and who have "at-risk" prosthesis, what is the effect of topical application of antimicrobials
and who have "at-risk" prosthesis, what is the effect of optimization of oral health
and who have "at-risk" prosthesis, what is the effect of extraction (full or partial mouth) on

and who have no teeth (edentulous), what is the effect of no intervention on the incidence,
and who have no teeth (edentulous), what is the effect of antibiotic prophylaxis on the

and who have no teeth (edentulous), what is the effect of topical application of antimicrobials
and who have no teeth (edentulous), what is the effect of optimization of oral health
instructions on the incidence, nature, duration, and magnitude of implant infection.

and who have no teeth (edentulous), what is the effect of extraction (full or partial mouth) on
and who have bisphosphonate therapy, what is the effect of no intervention on the incidence,
and who have bisphosphonate therapy, what is the effect of antibiotic prophylaxis on the

and who have bisphosphonate therapy, what is the effect of topical application of
and who have bisphosphonate therapy, what is the effect of optimization of oral health

and who have bisphosphonate therapy, what is the effect of extraction (full or partial mouth)

APPENDIX III
STUDY ATTRITION DIAGRAM
3702 abstracts reviewed (citation

identified by literature search
2475 abstracts
excluded
1227 articles recalled for full text

review
627 articles not

relevant to guideline
600 articles relevant for guideline
after further review and considered
for recommendations 198 articles not relevant
to bacteremia or
implant infection
evidence or not meeting
inclusion criteria
1 article of direct
213 articles of indirect evidence 188 articles of indirect
evidence on orthopaedic considered for evidence on post-dental
implant infection recommendations procedure bacteremia and
considered for prophylaxis considered for
background recommendations
microbiology
182 articles not 61 articles excluded

relevant to implant during best available
infection background 44 articles not relevant evidence evaluation
microbiology to bacteremia
background
microbiology
31 orthopaedic implant 127 articles considered for
infection articles and recommendations, 105 of
61 post-dental procedure these articles considered for
bacteremia articles considered background microbiology
for background microbiology.

INCLUDED STUDIES TABLES
RECOMMENDATION 1
Table 48 Included Studies for Recommendation 1
Author(s) Year Title
Berbari EF;Osmon DR;Carr A;Hanssen
AD;Baddour LM;Greene D;Kupp LI;Baughan Dental procedures as risk factors for prosthetic hip or knee
2010
LW;Harmsen WS;Mandrekar JN;Therneau infection: a hospital-based prospective case-control study
TM;Steckelberg JM;Virk A;Wilson WR;
Morozumi T;Kubota T;Abe D;Shimizu T;Komatsu Effects of irrigation with an antiseptic and oral administration of
2010
Y;Yoshie H; azithromycin on bacteremia caused by scaling and root planing
Lockhart PB;Brennan MT;Sasser HC;Fox

2008 Bacteremia associated with toothbrushing and dental extraction
PC;Paster BJ;Bahrani-Mougeot FK;
Brennan MT;Kent ML;Fox PC;Norton The impact of oral disease and nonsurgical treatment on
2007
HJ;Lockhart PB; bacteremia in children
Comparative efficacies of amoxicillin, clindamycin, and

Diz DP;Tomas C;Limeres PJ;Medina
2006 moxifloxacin in prevention of bacteremia following dental
HJ;Fernandez FJ;Alvarez FM;
extractions
Impact of amoxicillin prophylaxis on the incidence, nature, and

Lockhart PB;Brennan MT;Kent ML;Norton
2004 duration of bacteremia in children after intubation and dental
HJ;Weinrib DA;
procedures
Topical antibiotic prophylaxis for bacteremia after dental

Vergis EN;Demas PN;Vaccarello SJ;Yu VL; 2001
extractions
Clinical and microbiological efficacy of single dose cefuroxime

Wahlmann U;Al-Nawas B;Jutte M;Wagner W; 1999
prophylaxis for dental surgical procedures

Effects of prophylactic administration of cefaclor on transient
Hall G;Heimdahl A;Nord CE; 1996
bacteremia after dental extraction
Elimination of bacteraemia after dental extraction: comparison

Hall G;Nord CE;Heimdahl A; 1996 of erythromycin and clindamycin for prophylaxis of infective
endocarditis
Aitken C;Cannell H;Sefton AM;Kerawala Comparative efficacy of oral doses of clindamycin and
1995
C;Seymour A;Murphy M;Whiley RA;Williams JD; erythromycin in the prevention of bacteraemia
Prophylactic administration of penicillins for endocarditis does

Hall G;Hedstrom SA;Heimdahl A;Nord CE; 1993
not reduce the incidence of postextraction bacteremia
Antibacterial effects of ofloxacin, clindamycin and sultamicillin

Goker K;Guvener O; 1992
on surgical removal of impacted third molars
Incidence of transient bacteremia following dental surgery--

Katoh H; 1992
prophylactic use of cefuroxime, ceftriaxone or clindamycin
Cannell H;Kerawala C;Sefton AM;Maskell Failure of two macrolide antibiotics to prevent post-extraction
1991
JP;Seymour A;Sun ZM;Williams JD; bacteraemia
Coulter WA;Coffey A;Saunders ID;Emmerson

1990 Bacteremia in children following dental extraction
AM;
Casolari C;Neglia R;Forabosco A;Galetti R;Fabio

1989 Incidence of oral bacteremia and antimicrobial prophylaxis
U;
Prophylaxis of dental bacteraemia with oral amoxycillin in

Roberts GJ;Radford P;Holt R; 1987
children

Comparison of intravenous teicoplanin with intramuscular
Shanson DC;Shehata A;Tadayon M;Harris M; 1987 amoxycillin for the prophylaxis of streptococcal bacteraemia in
dental patients
Maskell JP;Carter JL;Boyd RB;Williams RJ; 1986 Teicoplanin as a prophylactic antibiotic for dental bacteraemia
Effect of phenoxymethylpenicillin and erythromycin

Josefsson K;Heimdahl A;von KL;Nord CE; 1985
prophylaxis on anaerobic bacteraemia after oral surgery
Erythromycin stearate, 1.5 g, for the oral prophylaxis of

Shanson DC;Akash S;Harris M;Tadayon M; 1985 streptococcal bacteraemia in patients undergoing dental
extraction: efficacy and tolerance
A comparative study of the effectiveness of metronidazole and

Head TW;Bentley KC;Millar EP;deVries JA; 1984 penicillin V in eliminating anaerobes from postextraction
bacteremias
Appleman MD;Sutter VL;Sims TN; 1982 Value of antibiotic prophylaxis in periodontal surgery
Baltch AL;Schaffer C;Hammer MC;Sutphen Bacteremia following dental cleaning in patients with and
1982
NT;Smith RP;Conroy J;Shayegani M; without penicillin prophylaxis
Amoxycillin compared with penicillin V for the prophylaxis of

Shanson DC;Cannon P;Wilks M; 1978
dental bacteraemia
Control of post-extraction bacteraemias in the penicillin-

DeVries J;Francis LE;Lang D; 1972
hypersensitive patient
Jokinen MA; 1970 Bacteremia following dental extraction and its prophylaxis

An effective antibiotic cover for the prevention of endocarditis
Khairat O; 1966
following dental and other post-operative bacteraemias
Martin WJ;Schirger A; 1964 Prevention of bacteremia after oral surgery
Studies on bacteremia following oral surgery: Some

Gutverg M; 1962 prophylactic approaches to bacteremia and the results of tissue
examination of excised gingival

RECOMMENDATION 2
Fine DH;Furgang D;McKiernan M;Tereski- An investigation of the effect of an essential oil mouthrinse on
2010
Bischio D;Ricci-Nittel D;Zhang P;Araujo MW; induced bacteraemia: a pilot study
2010
Pineiro A;Tomas I;Blanco J;Alvarez M;Seoane

2010 Bacteraemia following dental implants' placement
J;Diz P;
Effect of rinsing with povidone-iodine on bacteraemia due to

Cherry M;Daly CG;Mitchell D;Highfield J; 2007
scaling: a randomized-controlled trial
Tomas I;Alvarez M;Limeres J;Tomas M;Medina Effect of a chlorhexidine mouthwash on the risk of
2007
J;Otero JL;Diz P; postextraction bacteremia
Fourrier F;Dubois D;Pronnier P;Herbecq P;Leroy Effect of gingival and dental plaque antiseptic decontamination
O;Desmettre T;Pottier-Cau E;Boutigny H;Di 2005 on nosocomial infections acquired in the intensive care unit: a
PC;Durocher A;Roussel-Delvallez M; double-blind placebo-controlled multicenter study
Investigation of bacteremia after orthodontic banding and

Erverdi N;Acar A;Isguden B;Kadir T; 2001
debanding following chlorhexidine mouth wash application
Brown AR;Papasian CJ;Shultz P;Theisen Bacteremia and intraoral suture removal: can an antimicrobial
1998
FC;Shultz RE; rinse help?
Fine DH;Korik I;Furgang D;Myers R;Olshan Assessing pre-procedural subgingival irrigation and rinsing with
1996
A;Barnett ML;Vincent J; an antiseptic mouthrinse to reduce bacteremia
An analysis of bacteremias during dental extractions. A double-

Lockhart PB; 1996
blind, placebo-controlled study of chlorhexidine

Preventing post-treatment bacteremia: comparing topical
Rahn R;Schneider S;Diehl O;Schafer V;Shah PM; 1995
povidone-iodine and chlorhexidine
Effects of various antiseptics on bacteremia following tooth

Yamalik MK;Yucetas S;Abbasoglu U; 1992
extraction
Lofthus JE;Waki MY;Jolkovsky DL;Otomo- Bacteremia following subgingival irrigation and scaling and
1991
Corgel J;Newman MG;Flemmig T;Nachnani S; root planing
Waki MY;Jolkovsky DL;Otomo-Corgel J;Lofthus Effects of subgingival irrigation on bacteremia following

1990
JE;Nachnani S;Newman MG;Flemmig TF; scaling and root planing

U;
MacFarlane TW;Ferguson MM;Mulgrew CJ; 1984 Post-extraction bacteraemia: role of antiseptics and antibiotics
Jokinen MA; 1978 Prevention of postextraction bacteremia by local prophylaxis
Nitroblue tetrazolium and Limulus assays for bacteremia after

Sweet JB;Gill VJ;Chusid MJ;Elin RJ; 1978
dental extraction: effect of topical antiseptics
The incidence of post-extraction bacteremia after irrigation of

Nasif AS; 1977
the gingival sulcus with hydrogen peroxide solution
Local degerming with povidone-iodine, II. Prior to

Brenman HS;Randall E; 1974
gingivectomy
The effects of preoperative rinsing with cetylpyridinium

Huffman GG;Wood WH;Hausler WJ;Jensen J; 1974 chloride on bacteremia associated with the surgical removal of
impacted third molars

Effect of chlorhexidine mouthrinse and periodontal treatment
Madsen KL; 1974
upon bacteremia produced by oral hygiene procedures
Francis LE;DeVries J;Lang D; 1973 An oral antiseptic for the control of post-extraction bacteraemia
Cutcher JL;Goldberg JR;Lilly GE;Jones JC; 1971 Control of bacteremia associated with extraction of teeth. II
Gingival degerming by povidone-iodine irrigation: bacteremia

Scopp IW;Orvieto LD; 1971
reduction in extraction procedures
Jones JC;Cutcher JL;Goldberg JR;Lilly GE; 1970 Control of bacteremia associated with extraction of teeth

RECOMMENDATION 3
Barbosa M;Carmona IT;Amaral B;Limeres General anesthesia increases the risk of bacteremia following
2010
J;Alvarez M;Cerqueira C;Diz P; dental extractions
Ashare A;Stanford C;Hancock P;Stark D;Lilli

Chronic liver disease impairs bacterial clearance in a human
K;Birrer E;Nymon A;Doerschug KC;Hunninghake 2009
model of induced bacteremia
GW;
Crasta K;Daly CG;Mitchell D;Curtis B;Stewart

2009 Bacteraemia due to dental flossing
D;Heitz-Mayfield LJ;
Lockhart PB;Brennan MT;Thornhill

Poor oral hygiene as a risk factor for infective endocarditis-
M;Michalowicz BS;Noll J;Bahrani-Mougeot 2009
related bacteremia
FK;Sasser HC;
Incidence of bacteraemia following teeth extraction at the dental

Enabulele OI;Aluyi HSA;Omokao O; 2008 clinic of the University of Benin Teaching Hospital, Benin city,
Nigeria
Tomas I;Pereira F;Llucian R;Poveda R;Diz

2008 Prevalence of bacteraemia following third molar surgery
P;Bagan JV;
Valdes C;Tomas I;Alvarez M;Limeres J;Medina The incidence of bacteraemia associated with tracheal
2008
J;Diz P; intubation
Brennan MT;Kent ML;Fox PC;Norton The impact of oral disease and nonsurgical treatment on
2007
HJ;Lockhart PB; bacteremia in children


Incidence of bacteremia after chewing, tooth brushing and
Forner L;Larsen T;Kilian M;Holmstrup P; 2006
scaling in individuals with periodontal inflammation
Takai S;Kuriyama T;Yanagisawa M;Nakagawa Incidence and bacteriology of bacteremia associated with
2005
K;Karasawa T; various oral and maxillofacial surgical procedures
Transient bacteremia induced by toothbrushing a comparison of

Bhanji S;Williams B;Sheller B;Elwood T;Mancl L; 2002
the Sonicare toothbrush with a conventional toothbrush
Daly CG;Mitchell DH;Highfield JE;Grossberg Bacteremia due to periodontal probing: a clinical and
2001
DE;Stewart D; microbiological investigation
Clinical and microbiological efficacy of single dose cefuroxime

Wahlmann U;Al-Nawas B;Jutte M;Wagner W; 1999
prophylaxis for dental surgical procedures
Bacteremia of dental origin and antimicrobial sensitivity

Roberts GJ;Watts R;Longhurst P;Gardner P; 1998
following oral surgical procedures in children
Daly C;Mitchell D;Grossberg D;Highfield

1997 Bacteraemia caused by periodontal probing
J;Stewart D;
An analysis of bacteremias during dental extractions. A double-

Lockhart PB; 1996
blind, placebo-controlled study of chlorhexidine
Factors affecting the occurrence of bacteremia associated with

Okabe K;Nakagawa K;Yamamoto E; 1995
tooth extraction

AM;
Trivedi DN; 1984 Bacteraemia due to operative procedure

Experimental transient bacteraemias in human subjects with
Silver JG;Martin AW;McBride BC; 1977 varying degrees of plaque accumulation and gingival
inflammation
De Leo AA;Schoenknecht FD;Anderson The incidence of bacteremia following oral prophylaxis on

1974
MW;Peterson JC; pediatric patients
Evaluation of transient bacteremia following routine periodontal

Lineberger LT;De Marco TJ; 1973
procedures

DENTAL PROCEDURES AND BACTEREMIA
Table 51 Included Studies for Dental Procedures and Bacteremia
Barbosa M;Carmona IT;Amaral B;Limeres General anesthesia increases the risk of bacteremia following
2010
J;Alvarez M;Cerqueira C;Diz P; dental extractions
2010

J;Diz P;

Transient bacteremia after removal of a bonded maxillary

Gurel HG;Basciftci FA;Arslan U; 2009
expansion appliance
Nixon PP;Littler P;Davies K;Krishnam MS; 2009 Does sialography require antibiotic prophylaxis?
Prevalence, intensity and identity of bacteraemia following

Sonbol H;Spratt D;Roberts GJ;Lucas VS; 2009
conservative dental procedures in children
Incidence of bacteraemia following teeth extraction at the dental

Enabulele OI;Aluyi HSA;Omokao O; 2008 clinic of the University of Benin Teaching Hospital, Benin city,
Nigeria
Lockhart PB;Brennan MT;Sasser HC;Fox

2008 Bacteremia associated with toothbrushing and dental extraction
PC;Paster BJ;Bahrani-Mougeot FK;
Tomas I;Pereira F;Llucian R;Poveda R;Diz

2008 Prevalence of bacteraemia following third molar surgery
P;Bagan JV;

2008
J;Diz P; intubation

Lafaurie GI;Mayorga-Fayad I;Torres MF;Castillo Periodontopathic microorganisms in peripheric blood after

2007
DM;Aya MR;Baron A;Hurtado PA; scaling and root planing
Tomas I;Alvarez M;Limeres J;Potel C;Medina Prevalence, duration and aetiology of bacteraemia following
2007
J;Diz P; dental extractions
Tomas I;Alvarez M;Limeres J;Tomas M;Medina Effect of a chlorhexidine mouthwash on the risk of
2007
J;Otero JL;Diz P; postextraction bacteremia

Forner L;Nielsen CH;Bendtzen K;Larsen Increased plasma levels of IL-6 in bacteremic periodontis
2006
T;Holmstrup P; patients after scaling
Murphy AM;Daly CG;Mitchell DH;Stewart Chewing fails to induce oral bacteraemia in patients with
2006
D;Curtis BH; periodontal disease
Bacteremia incidence in pediatric patients under dental general

Oncag O;Aydemir S;Ersin N;Koca H; 2006
anesthesia
Kinane DF;Riggio MP;Walker KF;MacKenzie

2005 Bacteraemia following periodontal procedures
D;Shearer B;
Oncag O;Cokmez B;Aydemir S;Balcioglu T; 2005 Investigation of bacteremia following nasotracheal intubation

Savarrio L;MacKenzie D;Riggio M;Saunders Detection of bacteraemias during non-surgicalroot canal
2005
WP;Bagg J; treatment
Takai S;Kuriyama T;Yanagisawa M;Nakagawa Incidence and bacteriology of bacteremia associated with
2005
K;Karasawa T; various oral and maxillofacial surgical procedures
Burden DJ;Coulter WA;Johnston CD;Mullally The prevalence of bacteraemia on removal of fixed orthodontic
2004
B;Stevenson M; appliances
Rajasuo A;Nyfors S;Kanervo A;Jousimies-Somer

2004 Bacteremia after plate removal and tooth extraction
H;Lindqvist C;Suuronen R;
Rajasuo A;Perkki K;Nyfors S;Jousimies-Somer Bacteremia following surgical dental extraction with an
2004
H;Meurman JH; emphasis on anaerobic strains
Transient bacteremia induced by toothbrushing a comparison of

Bhanji S;Williams B;Sheller B;Elwood T;Mancl L; 2002
the Sonicare toothbrush with a conventional toothbrush
2001
DE;Stewart D; microbiological investigation
Odontogenic bacteremia following tooth cleaning procedures in

Lucas V;Roberts GJ; 2000
children
Roberts GJ;Gardner P;Longhurst P;Black Intensity of bacteraemia associated with conservative dental
2000
AE;Lucas VS; procedures in children
Erverdi N;Kadir T;Ozkan H;Acar A; 1999 Investigation of bacteremia after orthodontic banding
Brown AR;Papasian CJ;Shultz P;Theisen Bacteremia and intraoral suture removal: can an antimicrobial
1998
FC;Shultz RE; rinse help?

Roberts GJ;Simmons NB;Longhurst P;Hewitt PB; 1998 Bacteraemia following local anaesthetic injections in children
Bacteremia of dental origin and antimicrobial sensitivity

Roberts GJ;Watts R;Longhurst P;Gardner P; 1998
following oral surgical procedures in children

1997 Bacteraemia caused by periodontal probing
J;Stewart D;
Roberts GJ;Holzel HS;Sury MR;Simmons

1997 Dental bacteremia in children
NA;Gardner P;Longhurst P;
Debelian GJ;Olsen I;Tronstad L; 1995 Bacteremia in conjunction with endodontic therapy
Preventing post-treatment bacteremia: comparing topical

Rahn R;Schneider S;Diehl O;Schafer V;Shah PM; 1995
povidone-iodine and chlorhexidine
The occurrence of bacteraemia associated with the use of oral

Ali MT;Tremewen DR;Hay AJ;Wilkinson DJ; 1992
and nasopharyngeal airways
Giglio JA;Rowland RW;Dalton HP;Laskin DM; 1992 Suture removal-induced bacteremia: a possible endocarditis risk
Postscaling bacteremia in HIV-associated gingivitis and

Lucartorto FM;Franker CK;Maza J; 1992
periodontitis
Optimum sampling time for detection of dental bacteraemia in

Roberts GJ;Gardner P;Simmons NA; 1992
children
Lofthus JE;Waki MY;Jolkovsky DL;Otomo- Bacteremia following subgingival irrigation and scaling and
1991
Corgel J;Newman MG;Flemmig T;Nachnani S; root planing

AM;
Flood TR;Samaranayake LP;MacFarlane Bacteraemia following incision and drainage of dento-alveolar

1990
TW;McLennan A;MacKenzie D;Carmichael F; abscesses
Heimdahl A;Hall G;Hedberg M;Sandberg H;Soder Detection and quantitation by lysis-filtration of bacteremia after
1990
PO;Tuner K;Nord CE; different oral surgical procedures

1990
JE;Nachnani S;Newman MG;Flemmig TF; scaling and root planing

U;
Hansen CP;Westh H;Brok KE;Jensen R;Bertelsen Bacteraemia following orotracheal intubation and oesophageal
1989
S; balloon dilatation
King RC;Crawford JJ;Small EW; 1988 Bacteremia following intraoral suture removal
Dinner M;Tjeuw M;Artusio JF; 1987 Bacteremia as a complication of nasotracheal intubation

dental patients
Effect of phenoxymethylpenicillin and erythromycin

Josefsson K;Heimdahl A;von KL;Nord CE; 1985
prophylaxis on anaerobic bacteraemia after oral surgery

Lamey PJ;MacFarlane TW;Patton
1985 Bacteraemia consequential to sialography
DW;Samaranayake LP;Ferguson MM;
Marzoni FA;Kelly DR; 1983 Bacteremia following cleft palate repair--a prospective study
Relationship of bacteremia to toothbrushing in clinically healthy

Sconyers JR;Albers DD;Kelly R; 1979
patients

Silver JG;Martin AW;McBride BC; 1979
clinically healthy gingivae

dental bacteraemia
The incidence of transient bacteremia during periodontal

Wampole HS;Allen AL;Gross A; 1978
dressing change
Incidence of bacteremias related to endodontic procedures. II.

Baumgartner JC;Heggers JP;Harrison JW; 1977
Surgical endodontics

Soliman NA;el-Batawy YA;Abdallah AK; 1977 prophylactic approaches to bacteremia and the results of tissue
examination of excised gingiva
The incidence of bacteremias related to endodontic procedures.

I. Nonsurgical endodontics
The incidence of bacteremia in pediatric patients following

Peterson LJ;Peacock R; 1976
tooth extraction

A quantitative measurement of bacteremia and its relationship
Wank HA;Levison ME;Rose LF;Cohen DW; 1976
to plaque control
A study of transient bacteremia following the use of dental floss

Ramadan AE;Zaki SA;Nour ZM; 1975
silk and interdental stimulators
Bacteremia after the use of an oral irrigation device. A

Berger SA;Weitzman S;Edberg SC;Casey JI; 1974 controlled study in subjects with normal-appearing gingiva:
comparison with use of toothbrush
Crawford JJ;Sconyers JR;Moriarty JD;King Bacteremia after tooth extractions studied with the aid of
1974
RC;West JF; prereduced anaerobically sterilized culture media

1974
Comparison of bacteremia occurring with nasotracheal and

Berry FA;Blankenbaker WL;Ball CG; 1973
orotracheal intubation
Francis LE;DeVries J;Lang D; 1973 An oral antiseptic for the control of post-extraction bacteraemia

procedures
Relationship of bacteremia to toothbrushing in patients with

Sconyers JR;Crawford JJ;Moriarty JD; 1973
periodontitis
Degling TE; 1972 Orthodontics, bacteremia, and the heart damaged patient
Control of post-extraction bacteraemias in the penicillin-

hypersensitive patient

The American Academy of Periodontology 1972 Oral irrigation and bacteremia
Detection of bacteremia after the use of an oral irrigation device

Felix JE;Rosen S;App GR; 1971
in subjects with periodontitis
Bacteremia, a result from oral irrigation in subjects with

Romans AR;App GR; 1971
gingivitis
Study on bacteriemia in patients with pyorrhea alveolaris caused

Wada K;Tomizawa M;Sasaki I; 1968
by surgical operations
Bacteremias following periodontal scaling in patients with

Conner HD;Haberman S;Collings CK;Winford TE; 1967
healthy appearing gingiva
Khairat O; 1966 The non-aerobes of post-extraction bacteremia
Martin WJ;Schirger A; 1964 PREVENTION OF BACTEREMIA AFTER ORAL SURGERY
Bender IB;SELTZER S;TASHMAN S;MELOFF

1963 Dental procedures in patients with rheumatic heart disease
G;

Gutverg M; 1962 prophylactic approaches to bacteremia and the results of tissue
ROGOSA M;HAMPP EG;NEVIN TA;WAGNER Blood sampling and cultural studies in the detection of
1960
HN;DRISCOLL EJ;Baer PN; postoperative bacteremias
Winslow MB;KOBERNICK SD; 1960 Bacteremia after prophylaxis

BACKGROUND MICROBIOLOGY
Table 52 Included Studies for Background Microbiology
Munoz-Mahamud E;Garcia S;Bori G;Martinez- Comparison of a low-pressure and a high-pressure pulsatile
2011
Pastor JC;Zumbado JA;Riba J;Mensa J;Soriano A; lavage during debridement for orthopaedic implant infection
Berbari EF;Osmon DR;Carr A;Hanssen

AD;Baddour LM;Greene D;Kupp LI;Baughan Dental procedures as risk factors for prosthetic hip or knee
2010
LW;Harmsen WS;Mandrekar JN;Therneau infection: a hospital-based prospective case-control study
TM;Steckelberg JM;Virk A;Wilson WR;
Morozumi T;Kubota T;Abe D;Shimizu T;Komatsu Effect of irrigation with antiseptic and oral administration of
2010

J;Diz P;
Oral antibiotics are effective for highly resistant hip arthroplasty

Cordero-Ampuero J;Esteban J;Garcia-Cimbrelo E; 2009
infections

Transient bacteremia after removal of a bonded maxillary

Gurel HG;Basciftci FA;Arslan U; 2009
expansion appliance
Rodriguez D;Pigrau C;Euba G;Cobo J;Garcia-

Acute Hematogenous Prosthetic Joint Infection: Prospective
Lechuz J;Palomino J;Riera M;Del Toro 2009
Evaluation of Medical and Surgical Management
MD;Granados A;Ariza X;
Sancheti KH;Laud NS;Bhende H;Reddy G;Pramod The INDUS knee prosthesis - Prospective multicentric trial of a
2009
N;Mani JN; posteriorly stabilized high-flex design: 2 years follow-up

Uckay I;Lubbeke A;Emonet S;Tovmirzaeva
Low incidence of haematogenous seeding to total hip and knee
L;Stern R;Ferry T;Assal M;Bernard L;Lew 2009
prostheses in patients with remote infections
D;Hoffmeyer P;
Enabulele OI;Aluyi HSA;Omokao O; 2008 Incidence of bacteraemia following teeth extraction
The value of synovial biopsy, joint aspiration and C-reactive

Fink B;Makowiak C;Fuerst M;Berger I;Schafer
2008 protein in the diagnosis of late peri-prosthetic infection of total
P;Frommelt L;
knee replacements
Hamilton H;Jamieson J; 2008 Deep infection in total hip arthroplasty
2008
J;Diz P; intubation

Surgical debridement and parenteral antibiotics in infected

Chiu FY;Chen CM; 2007
revision total knee arthroplasty
Choong PF;Dowsey MM;Carr D;Daffy J;Stanley Risk factors associated with acute hip prosthetic joint infections
2007
P; and outcome of treatment with a rifampinbased regimen
Cordero-Ampuero J;Esteban J;Garcia-Cimbrelo Low relapse with oral antibiotics and two-stage exchange for
2007
E;Munuera L;Escobar R; late arthroplasty infections in 40 patients after 2-9 years
Lafaurie GI;Mayorga-Fayad I;Torres MF;Castillo Periodontopathic microorganisms in peripheric blood after

2007
DM;Aya MR;Baron A;Hurtado PA; scaling and root planning

Soriano A;Gomez J;Gomez L;Azanza JR;Perez Efficacy and tolerability of prolonged linezolid therapy in the
2007
R;Romero F;Pons M;Bella F;Velasco M;Mensa J; treatment of orthopedic implant infections

Forner L;Nielsen CH;Bendtzen K;Larsen Increased plasma levels of IL-6 in bacteremic periodontis
2006
T;Holmstrup P; patients after scaling
Revision total hip arthroplasty in juvenile chronic arthritis: 17

Goodman SB;Oh KJ;Imrie S;Hwang K;Shegog M; 2006
revisions in 11 patients followed for 4-12 years

Oncag O;Aydemir S;Ersin N;Koca H; 2006
anesthesia
Soriano A;Garcia S;Bori G;Almela M;Gallart

2006 Treatment of acute post-surgical infection of joint arthroplasty
X;Macule F;Sierra J;Martinez JA;Suso S;Mensa J;
Hoad-Reddick DA;Evans CR;Norman P;Stockley Is there a role for extended antibiotic therapy in a two-stage
2005
I; revision of the infected knee arthroplasty?
Kinane DF;Riggio MP;Walker KF;MacKenzie

2005 Bacteremia folloing periodontal procedures
D;Shearer B;

Oncag O;Cokmez B;Aydemir S;Balcioglu T; 2005
anesthesia
Burden DJ;Coulter WA;Johnston CD;Mullally The prevalence of bacteraemia on removal of fixed orthodontic
2004
B;Stevenson M; appliances

Rajasuo A;Nyfors S;Kanervo A;Jousimies-Somer
2004 Bacteremia after plate removal and tooth extraction
H;Lindqvist C;Suuronen R;
Jerosch J;Schneppenheim M; 2003 Management of infected shoulder replacement
Rao N;Crossett LS;Sinha RK;Le Frock JL; 2003 Long-term suppression of infection in total joint arthroplasty
Soultanis K;Mantelos G;Pagiatakis A;Soucacos Late infection in patients with scoliosis treated with spinal
2003
PN; instrumentation
2001
DE;Stewart D; micobiological investigation
Odontogenic bacteremia following tooth cleaning procedures in

children
Medium-term results of a modern metal-on-metal system in

Wagner M;Wagner H; 2000
total hip replacement
Infected total knee arthroplasty treated by arthroscopic irrigation

Waldman BJ;Hostin E;Mont MA;Hungerford DS; 2000
and debridement
Erverdi N;Kadir T;Ozkan H;Acar A; 1999 Investigation of bacteremia after orthodontic banding
Clinical experience with a proximally porous-coated second-

Mont MA;Yoon TR;Krackow KA;Hungerford DS; 1999 generation cementless total hip prosthesis: minimum 5-year
follow-up
Crockarell JR;Hanssen AD;Osmon DR;Morrey Treatment of infection with debridement and retention of the
1998
BF; components following hip arthroplasty

Metal-backed patellar component failure in total knee
Petrie RS;Hanssen AD;Osmon DR;Ilstrup D; 1998
arthroplasty: a possible risk for late infection
Cementless femoral revision arthroplasty. 2- to 5-year results

Smith JA;Dunn HK;Manaster BJ; 1998
with a modular titanium alloy stem
Influence of antibiotics on infection in spinal surgery: a

Wimmer C;Nogler M;Frischhut B; 1998
prospective study of 110 patients

1997 Bacteremia caused by periodontal probing
J;Stewart D;
Mont MA;Waldman B;Banerjee C;Pacheco Multiple irrigation, debridement, and retention of components in
1997
IH;Hungerford DS; infected total knee arthroplasty
Debelian GJ;Olsen I;Tronstad L; 1995 Bacteremia in conjunction with endodontic therapy
Antibacterial Effects of Ofloxacin, Clindamycin and

Goker K;Guvener O; 1992
Sultamicillin on Surgical Removal of Impacted Third Molars
Combined prophylactic effect of ultraclean air and cefuroxime

Klenerman L;Seal D;Sullens K; 1991
for reducing infection in prosthetic surgery
Flood TR;Samaranayake LP;MacFarlane Bacteraemia following incision and drainage of dento-alveolar

1990
TW;McLennan A;MacKenzie D;Carmichael F; abscesses
Heimdahl A;Hall G;Hedberg M;Sandberg H;Soder Detection and Quantitation by Lysis-Filtration of Bacteremia
1990
PO;Tuner K;Nord CE; after Different Oral Surgical Procedures

1990
JE;Nachnani S;Newman MG;Flemmig TF; scaling and rootplaning

Two-stage reimplantation for the salvage of total knee
Windsor RE;Insall JN;Urs WK;Miller DV;Brause
1990 arthroplasty complicated by infection. Further follow-up and
BD;
refinement of indications

U;
Hansen CP;Westh H;Brok KE;Jensen R;Bertelsen Bacteraemia following orotracheal intubation and oesophageal
1989
S; balloon dilatation
Dinner M;Tjeuw M;Artusio JF; 1987 Bacteremia as a Complication of Nasotrachael intubation

dental patients
Wroblewski BM; 1986 One-stage revision of infected cemented total hip arthroplasty
Lamey PJ;MacFarlane TW;Patton

1985 Bacteraemia consequential to sialography
DW;Samaranayake LP;Ferguson MM;
Ainscow DA;Denham RA; 1984 The risk of haematogenous infection in total joint replacements
Two-stage reimplantation for the salvage of infected total knee

Insall JN;Thompson FM;Brause BD; 1983
arthroplasty
Marzoni FA;Kelly DR; 1983 Bacteremia following cleft palate repair--a prospective study

Silver JG;Martin AW;McBride BC; 1979
clinically healthy gingivae

dental bacteraemia
Incidence of bacteremias related to endodontic procedures. II.

Surgical endodontics
Bacteriologic study of the systemic disturbances accompanying

Soliman NA;el-Batawy YA;Abdallah AK; 1977
primary teething
The incidence of bacteremias related to endodontic procedures.

I. Nonsurgical endodontics
The incidence of bacteremia in pediatric patients following

Peterson LJ;Peacock R; 1976
tooth extraction
A quantitative measurement of bacteremia and its relationship

Wank HA;Levison ME;Rose LF;Cohen DW; 1976
to plaque control
A study of transient bacteremia following the use of dental floss

Ramadan AE;Zaki SA;Nour ZM; 1975
silk and interdental stimulators
Bacteremia after the use of an oral irrigation device. A

Berger SA;Weitzman S;Edberg SC;Casey JI; 1974 controlled study in subjects with normal-appearing gingiva:
comparison with use of toothbrush
Local degerming with providone-iodine II. Prior ro

Brenman HS;Randall E; 1974
gingivectomy

1974
A Comparison of Bacteremia Occurring With Nasotracheal and

Berry FA;Blankenbaker WL;Ball CG; 1973
Orotracheal lntubation
Crawford JJ;Sconyers JR;Moriarty JD;King Bacteremia after tooth extractions studied with the aid of
1973
RC;West JF; prereduced anaerobically sterilized culture media

procedures
Relationship of bacteremia to toothbrushing in patients with

Sconyers JR;Crawford JJ;Moriarty JD; 1973
periodontitis
Detection of bacteremia after the use of an oral irrigation device

Felix JE;Rosen S;App GR; 1971
in subjects with periodontitis
Bacteremia, a result from oral irrigation in subjects with

Romans AR;App GR; 1971
gingivitis
Bacteremias following periodontal scaling in patients with

Conner HD;Haberman S;Collings CK;Winford TE; 1967
healthy appearing gingiva
Khairat O; 1966 The non-aerobes of post-extraction bacteremia
Martin WJ;Schirger A; 1964 Prevention of bacteremia after oral surgery
Studies on bacteremia following oral surgery: some

Gutverg M; 1962 prophylactic approaches to bacteremia and the result of tissue

ROGOSA M;HAMPP EG;NEVIN TA;WAGNER Blood sampling and cultural studies in the detection of
1960
HN;DRISCOLL EJ;Baer PN; postoperative bacteremias
Winslow MB;KOBERNICK SD; 1960 Bacteremia after prophylaxis

EXCLUDED STUDIES TABLES
RECOMMENDATION 1
Table 53 Excluded Studies for Recommendation 1
Author(s) Year Title Reason for Exclusion
Bahrani-Mougeot FK;Paster BJ;Coleman Diverse and novel oral bacterial species Relevant data previously
2008
S;Ashar J;Barbuto S;Lockhart PB; in blood following dental procedures published
Jeon HS;Hong SP;Cho BO;Mulyukin Hematogenous infection of the human

2005 Not best available evidence
A;Choi JY;Kim SG; temporomandibular joint
Roberts GJ;Holzel HS;Sury

MR;Simmons NA;Gardner P;Longhurst 1997 Dental bacteremia in children Split mouth design
P;
Blood culture positive rate of 3 media

(Bactec(registered trademark),
Aoki T;Kobayashi I; 1996 FAN(registered trademark), and VITAL n<10
ANA(registered trademark)) after tooth
extraction using imipenem
Intravenous administration of
Kaneko A;Sasaki J;Yamazaki
1995 vancomycin is ineffective against No control group
J;Kobayashi I;
bacteremia following tooth extraction
Transient bacteremia after tooth

Nohara T;Kobayashi I; 1995 extraction with intravenous cefuroxime No control group
prophylaxis
Transient bacteremia after tooth

Shirai T;Kobayashi I; 1995 extraction using ceftriaxone No control group
intravenously

Sasaki J;Otsuka T;Ozawa H;Takakura Transient bacteremia after tooth
1994 No control group
J;Kobayashi I; extraction using ampicillin intravenously
Comparative efficacy and tolerance of

Sefton AM;Maskell JP;Kerawala
erythromycin and josamycin in the
C;Cannell H;Seymour A;Sun 1990 Duplicate publication
prevention of bacteraemia following
ZM;Williams JD;
dental extraction
Gismondo MR;Nicoletti G; 1989 Prophylaxis of dental bacteremia Insufficient data for analysis
Bacteremia in patients undergoing oral

Baltch AL;Pressman HL;Schaffer procedures. Study following parenteral
C;Smith RP;Hammer MC;Shayegani 1988 antimicrobial prophylaxis as Insufficient data for analysis
M;Michelsen P; recommended by the American Heart
Association, 1977
Incidence of postextraction bacteremia

Hess J;Holloway Y;Dankert J; 1983 under penicillin cover in children with No control group
cardiac disease
Bacteremia following dental extractions

Baltch AL;Pressman HL;Hammer
1982 in patients with and without penicillin Insufficient data for analysis
MC;Sutphen NC;Smith RP;Shayegani M;
prophylaxis
Tolman DE;Schirger A;Martin Ampicillin administered prophylactically

WJ;Washington JA; in oral surgery
Martin WJ;Waite DE;Miller JJ;Schirger

1971 Oral surgery. Cloxacillin for prophylaxis No control group
A;

Benson DD;Waite DE;Hall WH;Carroll Omnipen (ampicillin) for prophylaxis.
GW; Prior to oral surgery
Streptococcal bacteraemia in children

Elliott RH;Dunbar JM; 1968 Not best available evidence
following dental extractions
Erythromycin for prophylaxis prior to

Schirger A;Waite DE;Martin WJ; 1968 oral surgery in patients allergic to No control group
panicillin
Cloxacillin for prophylaxis in oral

Waite DE;Schirger A;Martin WJ; 1967 No control group
surgery
Schirger A;Martin WJ;ROYER Bacterial invasion of blood after oral

1960 Duplicate publication
RO;NEEDHAM GM; surgical procedures

RECOMMENDATION 2
Effect of the diode laser on bacteremia
Assaf M;Yilmaz S;Kuru B;Ipci
2007 associated with dental ultrasonic scaling: Split mouth design
SD;Noyun U;Kadir T;
a clinical and microbiological study
Gingival degerming by povidone-iodine

Aguada E;Olona IL;Salazar MB; 1997 irrigation: bacteremia reduction in Blood drawn from sulcus
extraction procedures
The effect of topical Povidone-Iodine

Rahn R;Diehl O;Schafer V;Shah and Chlorhexidine on the incidence of
PM;Fleischer W;Reimer K; bacteremia following dental treatment
procedures
Prosol-chlorhexidine irrigation reduces

Allison C;Simor AE;Mock D;Tenenbaum the incidence of bacteremia during
1993 Split mouth design
HC; ultrasonic scaling with the Cavi-Med: a
pilot investigation
Effect of nonsterile versus sterile water

Reinhardt RA;Bolton RW;Hlava G; 1982 irrigation with ultrasonic scaling on Split mouth design
postoperative bacteremias
Effect of a local germicide on the

Witzenberger T;O'Leary TJ;Gillette WB; 1982 occurrence of bacteremia during Split mouth design
subgingival scaling
Effect of chlorhexidine mouthrinse and

Madsen KL; 1975 periodontal treatment upon bacteremia Duplicate publication
produced by oral hygiene procedures

Tamini HA;Norwood RS;August Use of antiseptics before injection to
AA;Dunkin RT;Eversole LR;Moser EH; minimize incidence of bacteremia
Topical vancomycin as a deterrent to

Bartlett RC;Howell RM; 1973 Split mouth design
bacteremias following dental procedures
Effectiveness of epinephrine in local

Eldirini AH; 1968 anesthetic solutions on the bacteremia Not topical antimicrobial
following dental extraction
Winslow MB;Millstone SH; 1965 Bacteremia after prophylaxis No control group
The influence of epinephrine on the

Louis JD; 1960 Not topical antimicrobial
incidence of bacteremia

RECOMMENDATION 3
Lafaurie GI;Mayorga-Fayad I;Torres 2007 Periodontopathic microorganisms in
No statistical test for prognostic
MF;Castillo DM;Aya MR;Baron peripheric blood after scaling and root
factors
A;Hurtado PA; planing
Tomas I;Alvarez M;Limeres J;Potel Prevalence, duration and aetiology of

C;Medina J;Diz P; bacteraemia following dental extractions
Murphy AM;Daly CG;Mitchell Chewing fails to induce oral bacteraemia No statistical test for prognostic
2006
DH;Stewart D;Curtis BH; in patients with periodontal disease factors
Intensity of bacteraemia associated with

Roberts GJ;Gardner P;Longhurst P;Black No statistical test for prognostic
2000 conservative dental procedures in
AE;Lucas VS; factors
children

subgingival scaling
A quantitative measurement of
Wank HA;Levison ME;Rose LF;Cohen
1976 bacteremia and its relationship to plaque Not best available evidence
DW;
control

Madsen KL; 1974 periodontal treatment upon bacteremia Not best available evidence

DENTAL PROCEDURES AND BACTEREMIA
Table 56 Excluded Studies for Dental Procedures and Bacteremia
Fine DH;Furgang D;McKiernan An investigation of the effect of an
M;Tereski-Bischio D;Ricci-Nittel 2010 essential oil mouthrinse on induced Not best available evidence
D;Zhang P;Araujo MW; bacteraemia: a pilot study
Jones DJ;Munro CL;Grap MJ;Kitten Oral care and bacteremia risk in

T;Edmond M; mechanically ventilated adults
Ashare A;Stanford C;Hancock P;Stark Chronic liver disease impairs bacterial

D;Lilli K;Birrer E;Nymon A;Doerschug 2009 clearance in a human model of induced Not best available evidence
KC;Hunninghake GW; bacteremia
Bahrani-Mougeot FK;Paster BJ;Coleman Diverse and novel oral bacterial species

S;Ashar J;Barbuto S;Lockhart PB; in blood following dental procedures
Lucas VS;Gafan G;Dewhurst S;Roberts Prevalence, intensity and nature of

GJ; bacteraemia after toothbrushing
Effect of the diode laser on bacteremia

Assaf M;Yilmaz S;Kuru B;Ipci
2007 associated with dental ultrasonic scaling: Split mouth design
SD;Noyun U;Kadir T;
a clinical and microbiological study
Lucas VS;Kyriazidou A;Gelbier Bacteraemia following debanding and

M;Roberts GJ; gold chain adjustment
Comparative efficacies of amoxicillin,

Diz DP;Tomas C;Limeres PJ;Medina clindamycin, and moxifloxacin in
HJ;Fernandez FJ;Alvarez FM; prevention of bacteremia following
dental extractions

Duration, prevalence and intensity of
Roberts GJ;Jaffray EC;Spratt DA;Petrie
2006 bacteraemia after dental extractions in Insufficient data for analysis
A;Greville C;Wilson M;Lucas VS;
children
Hartzell JD;Torres D;Kim P;Wortmann Incidence of bacteremia after routine

G; tooth brushing
Preliminary investigation of bacteremia

Rosa EA;Rached RN;Tanaka O;Fronza
2005 incidence after removal of the Haas n<10
F;Fronza F;Araujo AR;
palatal expander
The relationship between odontogenic

Lucas VS;Omar J;Vieira A;Roberts GJ; 2002 bacteraemia and orthodontic treatment Not best available evidence
procedures
Investigation of bacteremia after

orthodontic banding and debanding
Erverdi N;Acar A;Isguden B;Kadir T; 2001 Not best available evidence
following chlorhexidine mouth wash
application
Vergis EN;Demas PN;Vaccarello SJ;Yu Topical antibiotic prophylaxis for

2001 n<10
VL; bacteremia after dental extractions
Investigation of bacteremia following

Erverdi N;Biren S;Kadir T;Acar A; 2000 Not best available evidence
orthodontic debanding
Messini M;Skourti I;Markopulos

E;Koutsia-Carouzou C;Kyriakopoulou Bacteremia after dental treatment in Cannot determine bacteremia
1999
E;Kostaki S;Lambraki D;Georgopoulos mentally handicapped people incidence
A;

MR;Simmons NA;Gardner P;Longhurst 1997 Dental bacteremia in children Split mouth design
P;
McLaughlin JO;Coulter WA;Coffey The incidence of bacteremia after

A;Burden DJ; orthodontic banding
Factors affecting the occurrence of

Okabe K;Nakagawa K;Yamamoto E; 1995 bacteremia associated with tooth Not best available evidence
extraction
Transient bacteremia after tooth Cannot determine bacteremia

Morishima T;Sasaki J; 1994
extraction incidence
The effect of topical Povidone-Iodine

Rahn R;Diehl O;Schafer V;Shah and Chlorhexidine on the incidence of
PM;Fleischer W;Reimer K; bacteremia following dental treatment
procedures
Prosol-chlorhexidine irrigation reduces

Allison C;Simor AE;Mock D;Tenenbaum the incidence of bacteremia during
HC; ultrasonic scaling with the Cavi-Med: a
pilot investigation
Effects of various antiseptics on

Yamalik MK;Yucetas S;Abbasoglu U; 1992 Not best available evidence
bacteremia following tooth extraction
Toothbrushing and transient bacteremia

Schlein RA;Kudlick EM;Reindorf
1991 in patients undergoing orthodontic Not best available evidence
CA;Gregory J;Royal GC;
treatment

Hunter KM;Holborow DW;Kardos Bacteraemia and tissue damage resulting
TB;Lee-Knight CT;Ferguson MM; from air polishing
Bacteremia in patients undergoing oral

Baltch AL;Pressman HL;Schaffer procedures. Study following parenteral
C;Smith RP;Hammer MC;Shayegani 1988 antimicrobial prophylaxis as Insufficient data for analysis
M;Michelsen P; recommended by the American Heart
Association, 1977
Lewis HJ;Culligan GA;Pochee E;de Wet A microbiological investigation of post-

FA;Crewe-Brown HH; extraction bacteraemia in black subjects
Prophylaxis of dental bacteraemia with

Roberts GJ;Radford P;Holt R; 1987 Not best available evidence
oral amoxycillin in children
Toothbrushing and transient bacteremia

Chung A;Kudlick EM;Gregory JE;Royal
1986 in patients undergoing orthodontic Not best available evidence
GC;Reindorf CA;
treatment
Value of antibiotic prophylaxis in

Appleman MD;Sutter VL;Sims TN; 1982 Not best available evidence
periodontal surgery
Baltch AL;Schaffer C;Hammer Bacteremia following dental cleaning in

MC;Sutphen NT;Smith RP;Conroy 1982 patients with and without penicillin Not best available evidence
J;Shayegani M; prophylaxis
Effect of nonsterile versus sterile water

Reinhardt RA;Bolton RW;Hlava G; 1982 irrigation with ultrasonic scaling on Split mouth design
postoperative bacteremias

subgingival scaling
Dental flossing and its relationship to

Carroll GC;Sebor RJ; 1980 n<10
transient bacteremia
Nitroblue tetrazolium and Limulus assays

Sweet JB;Gill VJ;Chusid MJ;Elin RJ; 1978 for bacteremia after dental extraction: Not best available evidence
effect of topical antiseptics
Bacteraemia in asymptomatic human

Hockett RN;Loesche WJ;Sodeman TM; 1977 Insufficient data for analysis
subjects
The incidence of post-extraction

Nasif AS; 1977 bacteremia after irrigation of the gingival Not best available evidence
sulcus with hydrogen peroxide solution
Experimental transient bacteraemias in

human subjects with varying degrees of
Silver JG;Martin AW;McBride BC; 1977 Not best available evidence
plaque accumulation and gingival
inflammation
Speck WT;Spear SS;Krongrad E;Mandel Transient bacteremia in pediatric patients

L;Gersony WM; after dental extraction
Bacteremia in pediatric patients Cannot determine bacteremia

Faigel HC;Gaskill WF; 1975
following dental manipulations incidence

Madsen KL; 1975 periodontal treatment upon bacteremia Duplicate publication
Streptococci isolated from post-

Symington JM; 1975 Insufficient data for analysis
extraction bacteraemias
Tamini HA;Norwood RS;August Use of antiseptics before injection to

AA;Dunkin RT;Eversole LR;Moser EH; minimize incidence of bacteremia

Cannot determine bacteremia
Madsen KL; 1974 periodontal treatment upon bacteremia
incidence
Topical vancomycin as a deterrent to

Bartlett RC;Howell RM; 1973 Split mouth design
bacteremias following dental procedures
Berry FA;Yarbrough S;Yarbrough

Transient bacteremia during dental Cannot determine bacteremia
N;Russell CM;Carpenter MA;Hendley 1973
manipulation in children incidence
JO;
The incidence of transient bacteremia

Farrington FH; 1973 Not best available evidence
following pulpotomies on primary teeth
Cutcher JL;Goldberg JR;Lilly GE;Jones Control of bacteremia associated with

JC; extraction of teeth. II
Absence of bacteremia in children after

Hurwitz GA;Speck WT;Keller GB; 1971 Not best available evidence
prophylaxis

Transient bacteremia in pediatric patients
Speck WT;Hurwitz GA;Keller GB; 1971 Not best available evidence
following dental manipulatin
Bacteremia study using a water irrigation

Tamimi HA;Thomassen PR;Moser EH; 1969 Not best available evidence
device
Adjunctive use of antibiotics in traumatic

de Vries JA;Francis LE;Platonow M; 1968 Insufficient data for analysis
dental procedures
Effectiveness of epinephrine in local

Eldirini AH; 1968 anesthetic solutions on the bacteremia Not best available evidence
following dental extraction
An effective antibiotic cover for the

prevention of endocarditis following
Khairat O; 1966 Not best available evidence
dental and other post-operative
bacteraemias

BACKGROUND MICROBIOLOGY
Table 57 Excluded Studies for Background Microbiology
Modular femoral sleeve and stem implant
Le D;Smith K;Tanzer D;Tanzer M; 2011 Insufficient data for analysis
provides long-term total hip survivorship
Risk factors for subsequent diagnosis of

Aslam S;Reitman C;Darouiche RO; 2010 Retrospective study
prosthetic joint infection
Barbosa M;Carmona IT;Amaral

General anesthesia increases the risk of Insufficient data on bacteremia
B;Limeres J;Alvarez M;Cerqueira C;Diz 2010
bacteremia following dental extractions for background microbiology
P;
Prophylactic antibiotics do not affect

Burnett RS;Aggarwal A;Givens
2010 cultures in the treatment of an infected Insufficient data for analysis
SA;McClure JT;Morgan PM;Barrack RL;
TKA: a prospective trial
Results after late polymicrobial, gram-

Cordero-Ampuero J;Esteban J;Garcia-
2010 negative, and methicillin-resistant Insufficient data for analysis
Rey E;
infections in knee arthroplasty
Cementless two-staged total hip

arthroplasty with a short term interval
Erhart J;Jaklitsch K;Schurz M;Vecsei
2010 period for chronic deep periprosthetic Review
V;Ehall R;
infection. Technique and long-term
results
A two-stage retention debridement

Estes CS;Beauchamp CP;Clarke
2010 protocol for acute periprosthetic joint Retrospective study
HD;Spangehl MJ;
infections

Total knee replacement in patients with
Goddard NJ;Mann HA;Lee CA; 2010 end-stage haemophilic arthropathy: 25- Retrospective study
year results
Rates of infection and revision in patients

McCleery MA;Leach WJ;Norwood T; 2010 with renal disease undergoing total knee Insufficient data for analysis
replacement in Scotland
Two-stage total infected knee

Ocguder A;Firat A;Tecimel O;Solak
2010 arthroplasty treatment with articulating Insufficient data for analysis
S;Bozkurt M;
cement spacer
Outcome of Infected Total Joint

Ritter MA;Farris A; 2010 Retrospective study
Replacement
Rodriguez D;Pigrau C;Euba G;Cobo Acute haematogenous prosthetic joint

J;Garcia-Lechuz J;Palomino J;Riera 2010 infection: prospective evaluation of Duplicate Publication
M;Del Toro MD;Granados A;Ariza X; medical and surgical management
Sousa R;Pereira A;Massada M;da Silva Empirical antibiotic therapy in prosthetic

2010 Retrospective study
MV;Lemos R;Costa e Castro; joint infections
Prophylactic oral antibiotics reduce

Zywiel MG;Johnson AJ;Stroh DA;Martin
2010 reinfection rates following two-stage Retrospective study
J;Marker DR;Mont MA;
Aseptic loosening of cemented stem

Bin D;Noble PC; 2009 following cemented hip arthroplasty: Insufficient data for analysis
Analysis of 36 revised specimens

One hundred and twelve infected
Byren I;Bejon P;Atkins BL;Angus arthroplasties treated with 'DAIR'
B;Masters S;McLardy-Smith P;Gundle 2009 (debridement, antibiotics and implant Retrospective study
R;Berendt A; retention): antibiotic duration and
outcome
The Exeter Universal cemented femoral

Carrington NC;Sierra RJ;Gie GA;Hubble
2009 component at 15 to 17 years: an update Insufficient data for analysis
MJ;Timperley AJ;Howell JR;
on the first 325 hips
Cavusoglu AT;Er MS;Inal S;Ozsoy Pin site care during circular external
2009 Insufficient data for analysis
MH;Dincel VE;Sakaogullari A; fixation using two different protocols
Two-stage reimplantation of infected hip

Chen WS;Fu TH;Wang JW; 2009 Insufficient data for analysis
arthroplasties
Dale H;Hallan G;Hallan G;Espehaug Increasing risk of revision due to deep

B;Havelin LI;Engesaeter LB; infection after hip arthroplasty
Dauchy FA;Dupon M;Dutronc H;de Association between psoas abscess and

BB;Lawson-Ayayi S;Dubuisson 2009 prosthetic hip infection: a case-control Insufficient data for analysis
V;Souillac V; study
The Mayo cementless femoral

Goebel D;Schultz W; 2009 component in active patients with Insufficient data for analysis
osteoarthritis
Revision following cemented and

Hooper GJ;Rothwell AG;Stringer uncemented primary total hip
M;Frampton C; replacement: a seven-year analysis from
the New Zealand Joint Registry

Martinez-Pastor JC;Munoz-Mahamud Outcome of acute prosthetic joint
E;Vilchez F;Garcia-Ramiro S;Bori infections due to gram-negative bacilli
G;Sierra J;Martinez JA;Font L;Mensa treated with open debridement and
J;Soriano A; retention of the prosthesis
Nixon PP;Littler P;Davies K;Krishnam Does sialography require antibiotic Insufficient data on bacteremia
2009
MS; prophylaxis? for background microbiology
Prosthetic joint infection risk after total

Ong KL;Kurtz SM;Lau E;Bozic KJ;Berry
2009 hip arthroplasty in the Medicare Insufficient data for analysis
DJ;Parvizi J;
population
Effect of oral erythromycin therapy in

Ren W;Blasier R;Peng X;Shi T;Wooley
2009 patients with aseptic loosening of joint Insufficient data for analysis
PH;Markel D;
prostheses
Prevalence, intensity and identity of

Insufficient data on bacteremia
Sonbol H;Spratt D;Roberts GJ;Lucas VS; 2009 bacteraemia following conservative
for background microbiology
dental procedures in children
Microbiology of the infected knee

Stefansdottir A;Johansson D;Knutson arthroplasty: report from the Swedish
K;Lidgren L;Robertsson O; Knee Arthroplasty Register on 426
surgically revised cases
Prosthesis retention, serial debridement,

Tintle SM;Forsberg JA;Potter and antibiotic bead use for the treatment
2009 Review
BK;Islinger RB;Andersen RC; of infection following total joint
arthroplasty

Yoo JJ;Kwon YS;Koo KH;Yoon KS;Kim One-stage cementless revision
2009 Review
YM;Kim HJ; arthroplasty for infected hip replacements
Zeller V;Lavigne M;Leclerc P;Lhotellier Group B streptococcal prosthetic joint

L;Graff W;Ziza JM;Desplaces 2009 infections: a retrospective study of 30 Retrospective study
N;Mamoudy P; cases
Microbiology and management of joint

Brook I; 2008 and bone infections due to anaerobic Review
bacteria
Gosheger G;Goetze C;Hardes J;Joosten The influence of the alloy of

U;Winkelmann W;von EC; megaprostheses on infection rate
Wound complication of minimally

Lau TW;Leung F;Chan CF;Chow SP; 2008 invasive plate osteosynthesis in distal Retrospective study
tibia fractures
Leclercq S;Benoit JY;de Rosa JP;Euvrard Results of the Evora dual-mobility socket
P;Leteurtre C;Girardin P; after a minimum follow-up of five years
Lockhart PB;Brennan MT;Sasser

Bacteremia associated with Insufficient data on bacteremia
HC;Fox PC;Paster BJ;Bahrani-Mougeot 2008
toothbrushing and dental extraction for background microbiology
FK;
The use of linezolid in the treatment of

Oussedik SI;Haddad FS; 2008 Retrospective study
infected total joint arthroplasty
Parvizi J;Ghanem E;Azzam K;Davis Periprosthetic infection: are current

E;Jaberi F;Hozack W; treatment strategies adequate?

Maxillomandibular fixation using
intraoral cortical bone screws and
Poeschl PW;Ploder O;Seemann
2008 specially designed metal hooks Insufficient data for analysis
R;Poeschl E;
(Ottenhaken) in the conservative
treatment of mandibular fractures
Twenty-year survivorship of cementless

Ritter MA;Meneghini RM; 2008 anatomic graduated component (AGC) Insufficient data for analysis
total knee replacement
Prolonged bacterial culture to identify

Schafer P;Fink B;Sandow D;Margull
2008 late periprosthetic joint infection: a Insufficient data for analysis
A;Berger I;Frommelt L;
promising strategy
Tomas I;Pereira F;Llucian R;Poveda Prevalence of bacteraemia following Insufficient data on bacteremia
2008
R;Diz P;Bagan JV; third molar surgery for background microbiology
Treatment of staphylococcal prosthetic

Aboltins CA;Page MA;Buising
joint infections with debridement,
KL;Jenney AW;Daffy JR;Choong 2007 Retrospective study
prosthesis retention and oral rifampicin
PF;Stanley PA;
and fusidic acid
Byrne AM;Morris S;McCarthy Outcome following deep wound Study on perioperative

2007
T;Quinlan W;O'byrne JM; contamination in cemented arthroplasty contamination
Late hematogenous infections after total

Cook JL;Scott RD;Long WJ; 2007 knee arthroplasty: experience with 3013 Retrospective study
consecutive total knees

Frances A;Moro E;Cebrian JL;Marco Reconstruction of bone defects with
F;Garcia-Lopez A;Serfaty D;Lopez- 2007 impacted allograft in femoral stem Insufficient data for analysis
Duran L; revision surgery
Kowalski TJ;Berbari EF;Huddleston The management and outcome of spinal

PM;Steckelberg JM;Mandrekar 2007 implant infections: contemporary Retrospective study
JN;Osmon DR; retrospective cohort study
Efficacy and safety of linezolid for

Rao N;Hamilton CW; 2007 Gram-positive orthopedic infections: a Insufficient data for analysis
prospective case series
Infection at titanium implants with or

Renvert S;Roos-Jansaker AM;Lindahl
2007 without a clinical diagnosis of Insufficient data for analysis
C;Renvert H;Rutger PG;
inflammation
Treatment of haematogenous pyogenic

Sundararaj GD;Babu N;Amritanand
vertebral osteomyelitis by single-stage
R;Venkatesh K;Nithyananth M;Cherian 2007 Insufficient data for analysis
anterior debridement, grafting of the
VM;Lee VN;
defect and posterior instrumentation
Tomas I;Alvarez M;Limeres J;Potel Prevalence, duration and aetiology of Insufficient data on bacteremia
2007
C;Medina J;Diz P; bacteraemia following dental extractions for background microbiology
Tomas I;Alvarez M;Limeres J;Tomas Effect of a chlorhexidine mouthwash on Insufficient data on bacteremia
2007
M;Medina J;Otero JL;Diz P; the risk of postextraction bacteremia for background microbiology
You JH;Lee GC;So RK;Cheung KW;Hui Linezolid versus vancomycin for

2007 Simulation model
M; prosthetic joint infections: a cost analysis

Management of infections of
Barberan J; 2006 Review
osteoarticular prosthesis
Barberan J;Aguilar L;Carroquino Conservative treatment of staphylococcal

G;Gimenez MJ;Sanchez B;Martinez 2006 prosthetic joint infections in elderly Retrospective study
D;Prieto J; patients
Acetabular reconstruction with impacted

Comba F;Buttaro M;Pusso R;Piccaluga bone allografts and cemented acetabular
F; components: a 2- to 13-year follow-up
study of 142 aseptic revisions
Comparative efficacies of amoxicillin,

Diz DP;Tomas C;Limeres PJ;Medina clindamycin, and moxifloxacin in Insufficient data on bacteremia
2006
HJ;Fernandez FJ;Alvarez FM; prevention of bacteremia following for background microbiology
dental extractions
Does cement increase the risk of

infection in primary total hip
Engesaeter LB;Espehaug B;Lie arthroplasty? Revision rates in 56,275
SA;Furnes O;Havelin LI; cemented and uncemented primary THAs
followed for 0-16 years in the Norwegian
Arthroplasty Register
Fulkerson E;Valle CJ;Wise B;Walsh Antibiotic susceptibility of bacteria

2006 Review
M;Preston C;Di Cesare PE; infecting total joint arthroplasty sites
Outcome of prosthetic knee-associated

Laffer RR;Graber P;Ochsner
2006 infection: evaluation of 40 consecutive Retrospective study
PE;Zimmerli W;
episodes at a single centre

Late-onset infection of total knee
Lin C;Hsu H;Huang C;Chen S; 2006 arthroplasty caused by the Klebsiella Insufficient data for analysis
pneumoniae bacteremia
A randomized prospective controlled trial

of antibiotic prophylaxis in intraoral
Lindeboom JA;Frenken JW;Tuk
2006 bone-grafting procedures: preoperative Insufficient data for analysis
JG;Kroon FH;
single-dose penicillin versus preoperative
single-dose clindamycin
Impaction grafting for bone defects in

Lotke PA;Carolan GF;Puri N; 2006 Insufficient data for analysis
Murphy AM;Daly CG;Mitchell Chewing fails to induce oral bacteraemia Insufficient data on bacteremia
2006
DH;Stewart D;Curtis BH; in patients with periodontal disease for background microbiology
Rallis G;Mourouzis C;Papakosta Reasons for miniplate removal following

V;Papanastasiou G;Zachariades N; maxillofacial trauma: a 4-year study
Risk factors contributing to symptomatic

Theodossy T;Jackson O;Petrie A;Lloyd
2006 plate removal following sagittal split Insufficient data for analysis
T;
osteotomy
Bassetti M;Vitale F;Melica G;Righi E;Di

Linezolid in the treatment of Gram-
BA;Molfetta L;Pipino F;Cruciani 2005 Retrospective study
positive prosthetic joint infections
M;Bassetti D;
Late orthopaedic sequelae following

Belthur MV;Bradish CF;Gibbons PJ; 2005 meningococcal septicaemia. A Insufficient data for analysis
multicentre study

Chu VH;Crosslin DR;Friedman JY;Reed
SD;Cabell CH;Griffiths RI;Masselink Staphylococcus aureus bacteremia in
LE;Kaye KS;Corey GR;Reller 2005 patients with prosthetic devices: costs Insufficient data for analysis
LB;Stryjewski ME;Schulman KA;Fowler and outcomes
VG;
Souter-Strathclyde total elbow

Khatri M;Stirrat AN; 2005 arthroplasty in rheumatoid arthritis: Retrospective study
medium-term results
Marculescu CE;Berbari EF;Hanssen Prosthetic joint infection diagnosed

AD;Steckelberg JM;Osmon DR; postoperatively by intraoperative culture
Long-term results of primary total knee

Silva M;Luck JV; 2005 Review
replacement in patients with hemophilia
Incidence and bacteriology of bacteremia

Takai S;Kuriyama T;Yanagisawa Insufficient data on bacteremia
2005 associated with various oral and
M;Nakagawa K;Karasawa T; for background microbiology
maxillofacial surgical procedures
Durbhakula SM;Czajka J;Fuchs MD;Uhl Spacer endoprosthesis for the treatment

RL; of infected total hip arthroplasty
Bactericidal activity of antimicrobial

Forster H;Marotta JS;Heseltine K;Milner
2004 coated polyurethane sleeves for external Insufficient data for analysis
R;Jani S;
fixation pins
Ikavalko M;Belt EA;Kautiainen H;Lehto Souter arthroplasty for elbows with

MU; severe destruction

Implant removal for late-developing
infection after instrumented posterior
spinal fusion for scoliosis:
Muschik M;Luck W;Schlenzka D; 2004 Retrospective study
reinstrumentation reduces loss of
correction. A retrospective analysis of 45
cases
Pavoni GL;Giannella M;Falcone Conservative medical therapy of

M;Scorzolini L;Liberatore M;Carlesimo 2004 prosthetic joint infections: retrospective Retrospective study
B;Serra P;Venditti M; analysis of an 8-year experience
Bacteremia Following Surgical Dental

Rajasuo A;Perkki K;Nyfors S;Jousimies- Insufficient data on bacteremia
2004 Extraction with an Emphasis on
Somer H;Meurman JH; for background microbiology
Anaerobic Stra
Successful treatment of chronic bone and

Rao N;Ziran BH;Hall RA;Santa ER; 2004 Insufficient data for analysis
joint infections with oral linezolid
Savarrio L;MacKenzie D;Riggio Detection of bacteraemias during non- Insufficient data on bacteremia
2004
M;Saunders WP;Bagg J; surgicalroot canal treatment for background microbiology
Stavrev VP;Stavrev PV; 2004 Complications in total hip replacement Insufficient data for analysis
Survivorship analysis of Cotrel-

Bago J;Ramirez M;Pellise F;Villanueva
2003 Dubousset instrumentation in idiopathic Retrospective study
C;
scoliosis
Cemented revision of failed uncemented

Davis III CM;Berry DJ;Harmsen WS; 2003 femoral components of total hip Insufficient data for analysis
arthroplasty

Antibiotic prophylaxis in total hip
arthroplasty: Effects of antibiotic
prophylaxis systemically and in bone
Engesaeter LB;Lie SA;Espehaug
2003 cement on the revision rate of 22,170 Insufficient data for analysis
B;Furnes O;Vollset SE;Havelin LI;
primary hip replacements followed 0-14
years in the Norwegian Arthroplasty
Register
Gallo J;Kolar M;Novotny R;Rihakova Pathogenesis of prosthesis-related

2003 Review
P;Ticha V; infection
Ross JJ;Saltzman CL;Carling P;Shapiro Pneumococcal septic arthritis: review of

DS; 190 cases
Transient bacteremia induced by

Bhanji S;Williams B;Sheller B;Elwood toothbrushing a comparison of the Insufficient data on bacteremia
2002
T;Mancl L; Sonicare toothbrush with a conventional for background microbiology
toothbrush
Clinical outcome after treatment of

Husted H;Toftgaard JT; 2002 Retrospective study
infected primary total knee arthroplasty
Norian JM;Ries MD;Karp S;Hambleton Total knee arthroplasty in hemophilic

J; arthropathy
Unicompartmental knee arthroplasty: 3-

Perkins TR;Gunckle W; 2002 to 10-year results in a community Insufficient data for analysis
hospital setting
Revision cup arthroplasty using Burch-

van Koeveringe AJ;Ochsner PE; 2002 Insufficient data for analysis
Schneider anti-protrusio cage

Nine-year results of Muller cemented
Acklin YP;Berli BJ;Frick W;Elke
2001 titanium Straight Stems in total hip Insufficient data for analysis
R;Morscher EW;
replacement
Chiu KY;Ng TP;Tang WM;Poon KC;Ho Charnley total hip arthroplasty in

WY;Yip D; Chinese patients less than 40 years old
The intercellular adhesin locus ica is

present in clinical isolates of
Fowler VG;Fey PD;Reller LB;Chamis
2001 Staphylococcus aureus from bacteremic Insufficient data for analysis
AL;Corey GR;Rupp ME;
patients with infected and uninfected
prosthetic joints
Fractured rheumatoid elbow: treatment

Ikavalko M;Lehto MU; 2001 with Souter elbow arthroplasty--a clinical Insufficient data for analysis
and radiologic midterm follow-up study
Murdoch DR;Roberts SA;Fowler Jr

Infection of orthopedic prostheses after
VGJ;Shah MA;Taylor SL;Morris 2001 Insufficient data for analysis
Staphylococcus aureus bacteremia
AJ;Corey GR;
Delayed infections after posterior TSRH

Richards BR;Emara KM; 2001 spinal instrumentation for idiopathic Retrospective study
scoliosis: revisited
Vergis EN;Demas PN;Vaccarello SJ;Yu Topical antibiotic prophylaxis for Insufficient data on bacteremia
2001
VL; bacteremia after dental extractions for background microbiology

Reduction and fixation of sacroiliac joint
dislocation by the combined use of S1
Abumi K;Saita M;Iida T;Kaneda K; 2000 Insufficient data for analysis
pedicle screws and the galveston
technique
Regional prophylaxis with teicoplanin in

De LF;Viola R;Pellizzer G;Lazzarini
2000 monolateral or bilateral total knee Insufficient data for analysis
L;Tramarin A;Fabris P;
replacement: an open study
Gordon JE;Kelly-Hahn J;Carpenter Pin site care during external fixation in

CJ;Schoenecker PL; children: results of a nihilistic approach
Duration of postoperative antibiotic

Houshian S;Zawadski AS;Riegels-
2000 therapy following revision for infected Retrospective study
Nielsen P;
knee and hip arthroplasties
Augmented amputations of the lower

Mohler DG;Kessler JI;Earp BE; 2000 Retrospective study
extremity
Intensity of bacteraemia associated with

Roberts GJ;Gardner P;Longhurst P;Black Insufficient data on bacteremia
2000 conservative dental procedures in
AE;Lucas VS; for background microbiology
children
Aydinli U;Karaeminogullari O;Tiskaya Postoperative deep wound infection in

K; instrumented spinal surgery
Precoated femoral component in total hip

Brown EC;Lachiewicz PF; 1999 arthroplasty. Results of 5- to 9-year Retrospective study
followup

High placement of an acetabular
component inserted without cement in a
Dearborn JT;Harris WH; 1999 Retrospective study
revision total hip arthroplasty. Results
after a mean of ten years
Cementless fixation in 2-stage

Fehring TK;Calton TF;Griffin WL; 1999 Retrospective study
reimplantation for periprosthetic sepsis
The arthroscopic drainage, irrigation, and

Hyman JL;Salvati EA;Laurencin debridement of late, acute total hip
CT;Rogers DE;Maynard M;Brause DB; arthroplasty infections: average 6-year
follow-up
Two-stage treatment of chronic

staphylococcal orthopaedic implant-
Isiklar ZU;Demirors H;Akpinar
1999 related infections using vancomycin Insufficient data for analysis
S;Tandogan RN;Alparslan M;
impregnated PMMA spacer and rifampin
containing antibiotic protocol
Impaction allografting with cement for

Leopold SS;Berger RA;Rosenberg revision of the femoral component. A
AG;Jacobs JJ;Quigley LR;Galante JO; minimum four-year follow-up study with
use of a precoated femoral stem
Odontogenic bacteremia following tooth Insufficient data on bacteremia

cleaning procedures in children for background microbiology
Eliminating patellofemoral complications

Mont MA;Yoon TR;Krackow in total knee arthroplasty: clinical and
KA;Hungerford DS; radiographic results of 121 consecutive
cases using the Duracon system

Infection after total knee arthroplasty. A
Segawa H;Tsukayama DT;Kyle
1999 retrospective study of the treatment of Retrospective study
RF;Becker DA;Gustilo RB;
eighty-one infections
Pelvic reconstruction for severe

Vena VE;Hsu J;Rosier RN;O'Keefe RJ; 1999 Retrospective study
periacetabular metastatic disease
Survival analysis of the Harris-Galante I

Bohm P;Bosche R; 1998 Insufficient data for analysis
acetabular cup
Treatment of high dislocation of the hip

Hartofilakidis G;Stamos K;Karachalios in adults with total hip arthroplasty.
T; Operative technique and long-term
clinical results
Ankle arthroplasty for rheumatoid

arthritis and osteoarthritis: prospective
Kofoed H;Sorensen TS; 1998 Insufficient data for analysis
long-term study of cemented
replacements
Results of total hip replacement in renal

Lo NN;Tan JS;Tan SK;Vathsala A; 1998 Insufficient data for analysis
transplant recipients
Roberts GJ;Simmons NB;Longhurst Bacteraemia following local anaesthetic Insufficient data on bacteremia
1998
P;Hewitt PB; injections in children for background microbiology
Bacteremia of dental origin and

Roberts GJ;Watts R;Longhurst P;Gardner Insufficient data on bacteremia
1998 antimicrobial sensitivity following oral
P; for background microbiology
surgical procedures in children

Ambulatory treatment of multidrug-
resistant Staphylococcus-infected
Stein A;Bataille JF;Drancourt M;Curvale
1998 orthopedic implants with high-dose oral Insufficient data for analysis
G;Argenson JN;Groulier P;Raoult D;
co-trimoxazole (trimethoprim-
sulfamethoxazole)
Total knee replacement in young, active

Diduch DR;Insall JN;Scott WN;Scuderi
1997 patients. Long-term follow-up and Insufficient data for analysis
GR;Font-Rodriguez D;
functional outcome
Oral treatment of Staphylococcus spp.

Drancourt M;Stein A;Argenson infected orthopaedic implants with
JN;Roiron R;Groulier P;Raoult D; fusidic acid or ofloxacin in combination
with rifampicin
Three-to 7-year results with the

Grunig R;Morscher E;Ochsner PE; 1997 uncemented SL femoral revision Insufficient data for analysis
prosthesis
Incidence and sources of native and

Kaandorp CJ;Dinant HJ;van de Laar
1997 prosthetic joint infection: a community Insufficient data for analysis
MA;Moens HJ;Prins AP;Dijkmans BA;
based prospective survey
Charnley total hip arthroplasty with use

Madey SM;Callaghan JJ;Olejniczak of improved techniques of cementing.
JP;Goetz DD;Johnston RC; The results after a minimum of fifteen
years of follow-up
Total hip arthroplasty with an

McLaughlin JR;Lee KR; 1997 uncemented femoral component. Insufficient data for analysis
Excellent results at ten-year follow-up

Nijhof MW;Oyen WJ;van KA;Claessens Hip and knee arthroplasty infection. In-
RA;van der Meer JW;Corstens FH; 111-IgG scintigraphy in 102 cases
Intramedullary, antibiotic-loaded
Ozaki T;Hillmann A;Bettin D;Wuisman cemented, massive allografts for skeletal
P;Winkelmann W; reconstruction. 26 cases compared with
19 uncemented allografts

MR;Simmons NA;Gardner P;Longhurst 1997 Dental bacteremia in children
P;
Incidence of deep sepsis in uncemented

total hip arthroplasty using clean air
Hauser R;Berchtold W;Schreiber A; 1996 Retrospective study
facility as a function of antibiotic
prophylaxis
Two-stage cementless revision THR after

Lai KA;Shen WJ;Yang CY;Lin RM;Lin
1996 infection. 5 recurrences in 40 cases Retrospective study
CJ;Jou IM;
followed 2.5-7 years
Simultaneous bilateral total knee

Lu H;Mehdi G;Zhou D;Lin J; 1996 Insufficient data for analysis
arthroplasty for rheumatoid arthritis
The prosthesis-bone interface adjacent to

Silverton C;Rosenberg AO;Barden tibial components inserted without
RM;Sheinkop MB;Galante JO; cement. Clinical and radiographic
follow-up at nine to twelve years

Infection after total hip arthroplasty. A
Tsukayama DT;Estrada R;Gustilo RB; 1996 study of the treatment of one hundred Retrospective study
and six infections
Management of postoperative wound

Wimmer C;Gluch H; 1996 infection in posterior spinal fusion with Retrospective study
instrumentation
Aglietti P;Buzzi R;Segoni F;Zaccherotti Insall-Burstein posterior-stabilized knee

G; prosthesis in rheumatoid arthritis
Patient outcome with reinfection

Hanssen AD;Trousdale RT;Osmon DR; 1995 following reimplantation for the infected Retrospective study
total knee arthroplasty
Bell RS;Davis A;Allan DG;Langer Fresh osteochondral allografts for

F;Czitrom AA;Gross AE; advanced giant cell tumors at the knee
Revision of infected hip replacement.

Ivarsson I;Wahlstrom O;Djerf
1994 Two-stage procedure with a temporary Retrospective study
K;Jacobsson SA;
gentamicin spacer
Mauriello JA;Hargrave S;Yee Infection after insertion of alloplastic

S;Mostafavi R;Kapila R; orbital floor implants
The incidence of sepsis after total hip

Nasser S; 1994 Insufficient data for analysis
replacement arthroplasty
Petrou G;Gavras M;Diamantopoulos

Uncemented total hip replacements and
A;Kapetsis T;Kremmydas N;Kouzoupis 1994 Retrospective study
thigh pain
A;

Preventing post-treatment bacteremia:
Rahn R;Schneider S;Diehl O;Schafer Insufficient data on bacteremia
1994 comparing topical povidone-iodine and
V;Shah PM; for background microbiology
chlorhexidine
A multicenter 10-year study of cemented

revision total hip arthroplasty in patients
Stromberg CN;Herberts P; 1994 Insufficient data for analysis
younger than 55 years old. A follow-up
report
Oral rifampin plus ofloxacin for

Drancourt M;Stein A;Argenson
1993 treatment of Staphylococcus-infected Insufficient data for analysis
JN;Zannier A;Curvale G;Raoult D;
orthopedic implants
Anterior decompression and plate

Laus M;Pignatti G;Tigani D;Alfonso
1993 fixation in fracture dislocations of the Insufficient data for analysis
C;Giunti A;
lower cervical spine
Moeckel B;Huo MH;Salvati EA;Pellicci Total hip arthroplasty in patients with

PM; diabetes mellitus
A pilot study of oral fleroxacin given

Putz PA; 1993 once daily in patients with bone and joint Insufficient data for analysis
infections
Ceramic endoprosthesis in total hip

Riska EB; 1993 Insufficient data for analysis
arthroplasty
The occurrence of bacteremia associated

Ali MT;Tremewen DR;Hay Insufficient data on bacteremia
1992 with the use of oral and nasopharyngeal
AJ;Wilkinson DJ; for background microbiology
airways

Teicoplanin--home therapy for prosthetic
Davey PG;Rowley DR;Phillips GA; 1992 Insufficient data for analysis
joint infections
Postscaling becteremia in HIV-associated Insufficient data on bacteremia

Lucartorto FM;Franker CK;Maza J; 1992
gingivitis and periodontitis for background microbiology
Mason JC;Dollery CT;So A;Cohen

An infected prosthetic hip. Is there a role
J;Bloom SR;Bulpitt C;Russell-Jones 1992 Retrospective study
for prophylactic antibiotics?
R;Oakley CM;
Antimicrobial treatment of peri-implant

Mombelli A;Lang NP; 1992 Insufficient data for analysis
infections
Optimum sampling time for detection of Insufficient data on bacteremia

Roberts GJ;Gardner P;Simmons NA; 1992
dental bacteraemia in children for background microbiology
Etiology of deep sepsis in total hip

Schmalzried TP;Amstutz HC;Au
1992 arthroplasty. The significance of Retrospective study
MK;Dorey FJ;
hematogenous and recurrent infections
Results of cementless total knee

Armstrong RA;Whiteside LA; 1991 arthroplasty in an older rheumatoid Insufficient data for analysis
arthritis population
Lofthus JE;Waki MY;Jolkovsky

Bacteremia following subgingival Insufficient data on bacteremia
DL;Otomo-Corgel J;Newman 1991
irrigation and scaling and root planing for background microbiology
MG;Flemmig T;Nachnani S;
Mathiesen EB;Lindgren JU;Blomgren

1991 Corrosion of modular hip prostheses Retrospective study
GG;Reinholt FP;

Effect of time of onset and depth of
Rasul AT;Tsukayama D;Gustilo RB; 1991 infection on the outcome of total knee Retrospective study
arthroplasty infections
Sanderson PJ; 1991 Infection in orthopaedic implants Review
Swanson AB;de Groot SG;Masada

K;Makino M;Pires PR;Gannon 1991 Constrained total elbow arthroplasty Insufficient data for analysis
DM;Sattel AB;
Coulter WA;Coffey A;Saunders Bacteremia in children following dental Insufficient data on bacteremia
1990
ID;Emmerson AM; extraction for background microbiology
Kelly PJ;Fitzgerald RH;Cabanela

Results of treatment of tibial and femoral
ME;Wood MB;Cooney WP;Arnold 1990 Insufficient data for analysis
osteomyelitis in adults
PG;Irons GB;
Mnaymneh W;Emerson RH;Borja Massive allografts in salvage revisions of

F;Head WC;Malinin TI; failed total knee arthroplasties
Stern SH;Insall JN; 1990 Total knee arthroplasty in obese patients Insufficient data for analysis
Infection as a complication of total knee-

Wilson MG;Kelley K;Thornhill TS; 1990 replacement arthroplasty. Risk factors Retrospective study
and treatment in sixty-seven cases
Wymenga AB;Van Dijke BJ;Van Horn Prosthesis-related infection. Etiology,

1990 Review
JR;Slooff TJ; prophylaxis and diagnosis (a review)

Treatment of hematogenous pyogenic
Emery SE;Chan DP;Woodward HR; 1989 vertebral osteomyelitis with anterior Insufficient data for analysis
debridement and primary bone grafting
Treatment of major wound necrosis

Lian G;Cracchiolo A;Lesavoy M; 1989 Retrospective study
following total knee arthroplasty
Eskola A;Santavirta S;Konttinen Cementless total replacement for old

YT;Tallroth K;Hoikka V;Lindholm ST; tuberculosis of the hip
Goulet JA;Pellicci PM;Brause Prolonged suppression of infection in

BD;Salvati EM; total hip arthroplasty
Revision total hip arthroplasty with

titanium ingrowth prosthesis and bone
Gustilo RB;Pasternak HS; 1988 Insufficient data for analysis
grafting for failed cemented femoral
component loosening
An evaluation of the mechanical failure

Kester MA;Cook SD;Harding
1988 modalities of a rotating hinge knee Insufficient data for analysis
AF;Rodriguez RP;Pipkin CS;
prosthesis
Unicompartmental knee arthroplasty. A

Larsson SE;Larsson S;Lundkvist S; 1988 prospective consecutive series followed Insufficient data for analysis
for six to 11 years
Late infections of total joint prostheses.

Maderazo EG;Judson S;Pasternak H; 1988 A review and recommendations for Review
prevention

Nongenitourinary infections caused by
Madoff S;Hooper DC; 1988 Retrospective study
Mycoplasma hominis in adults
Deep-wound infection after total hip

Schutzer SF;Harris WH; 1988 replacement under contemporary aseptic Retrospective study
conditions
Bengtson S;Blomgren G;Knutson Hematogenous infection after knee

K;Wigren A;Lidgren L; arthroplasty
Streptococcus mitis. A cause of serious

Catto BA;Jacobs MR;Shlaes DM; 1987 Insufficient data for analysis
infection in adults
Comparative toxicity of total lymphoid

irradiation and immunosuppressive drug
Sherrer Y;Bloch D;Strober S;Fries J; 1987 Insufficient data for analysis
treated patients with intractable
rheumatoid arthritis
Treatment of chronic osteomyelitis with

Stuyck J;Verbist L;Mulier JC; 1987 Retrospective study
ciprofloxacin
Unger AS;Inglis AE;Ranawat Total hip arthroplasty in rheumatoid

CS;Johanson NA; arthritis. A long-term follow-up study
Deep sepsis following total knee

Grogan TJ;Dorey F;Rollins J;Amstutz arthroplasty. Ten-year experience at the
HC; University of California at Los Angeles
Medical Center
Experience with Charnley low-friction

Terayama K; 1986 Insufficient data for analysis
arthroplasty in Japan

Hip implant infection. Treatment with
Fitzgerald RH;Jones DR; 1985 resection arthroplasty and late total hip Retrospective study
arthroplasty
Effect of phenoxymethylpenicillin and

Josefsson K;Heimdahl A;von KL;Nord Insufficient data on bacteremia
1985 erythromycin prophylaxis on anaerobic
CE; for background microbiology
bacteraemia after oral surgery
Lachiewicz PF;Inglis AE;Insall

1985 Total knee arthroplasty in hemophilia Retrospective study
JN;Sculco TP;Hilgartner MW;Bussel JB;
Treatment of primary osteoarthritis of the

Amstutz HC;Thomas BJ;Jinnah R;Kim
1984 hip. A comparison of total joint and Retrospective study
W;Grogan T;Yale C;
surface replacement arthroplasty
Rifampicin in the treatment of

Cluzel RA;Lopitaux R;Sirot J;Rampon S; 1984 osteoarticular infections due to Insufficient data for analysis
staphylococci
Inman RD;Gallegos KV;Brause Clinical and microbial features of

BD;Redecha PB;Christian CL; prosthetic joint infection
Factors influencing the incidence and

Poss R;Thornhill TS;Ewald FC;Thomas
1984 outcome of infection following total joint Retrospective study
WH;Batte NJ;Sledge CB;
arthroplasty

An analysis of the causes of deep

Glynn MK;Sheehan JM; 1983 Retrospective study
infection after hip and knee arthroplasties

A non-surgical approach to preventing
Ritter MA;Sieber JM; 1983 hematogenous infections in total joint Retrospective study
replacements
Infection after total joint arthroplasty

Thomas BJ;Moreland JR;Amstutz HC; 1983 Retrospective study
from distal extremity sepsis
Medical and surgical treatment of the

Miley GB;Scheller AD;Turner RH; 1982 septic hip with one-stage revision Retrospective study
arthroplasty
Migration of the femoral stem in hip

arthroplasties. Analysis of associations
Soreide O;Lillestol J;Alho A;Hvidsten K; 1982 Insufficient data for analysis
with structural, radiological and follow-
up variables
Stinchfield FE;Bigliani LU;Neu HC;Goss Late hematogenous infection of total

TP;Foster CR; joint replacement
Treatment of subacute sepsis of the hip

Hughes PW;Salvati EA;Wilson by antibiotics and joint replacement.
PD;Blumenfeld EL; Criteria for diagnosis with evaluation of
twenty-six cases
Relationship of bacteremia to
Sconyers JR;Albers DD;Kelly R; 1979 toothbrushing in clinically healthy
patients
Excision arthroplasty with delayed

Mallory TH; 1978 wound closure for the infected total hip Retrospective study
replacement

Hematogenous infection of total knee
Marmor L;Berkus D; 1978 Retrospective study
implants
The incidence of transient bacteremia Insufficient data on bacteremia

Wampole HS;Allen AL;Gross A; 1978
during periodontal dressing change for background microbiology
A comparison of dicloxacillin and

Visuri T;Antila P;Laurent LE; 1976 ampicillin in the antibiotic prophylaxis of Insufficient data for analysis
total hip replacement
Millender LH;Nalebuff EA;Hawkins Infection after silicone prosthetic

RB;Ennis R; arthroplasty in the hand
Subacute sepsis of the hip treated by

Wilson PD;Aglietti P;Salvati EA; 1974 Retrospective study
antibiotics and cemented prosthesis
An oral antiseptic for the control of post- Insufficient data on bacteremia

Francis LE;DeVries J;Lang D; 1973
extraction bacteraemia for background microbiology
Roberts GJ;Simmons NB;Longhurst Evaluation of transient bacteremia Insufficient data on bacteremia

1973
P;Hewitt PB; following routine periodontal procedures for background microbiology

America Academy of Periodontology 1972 Oral irrigation and bacteremia
Orthodontics, bacteremia, and the heart Insufficient data on bacteremia

Degling TE; 1972
damaged patient for background microbiology
Control of post-extraction bacteraemias Insufficient data on bacteremia

in the penicillin-hypersensitive patient for background microbiology

Study on bacteriemia in patients of
Wada K;Tomizawa M;Sasaki I; 1968 pyorrhea Alveolaris caused by surgical
operations
Bender IB;SELTZER S;TASHMAN Dental procedures in patients with Insufficient data on bacteremia
1963
S;MELOFF G; rheumatic heart disease for background microbiology

PUBLICATIONS EXCLUDED DURING FULL TEXT REVIEW
Table 58 Excluded Studies Identified During Full Text Review
Need for antibiotic premedication for
Ashrafi SS;Nakib N; 2011 patients having periodontal dental Review
procedures
Detection of specific periodontal

Castillo DM;Sanchez-Beltran
microorganisms from bacteraemia
MC;Castellanos JE;Sanz I;Mayorga- 2011 Comparison of testing methods
samples after periodontal therapy using
Fayad I;Sanz M;Lafaurie GI;
molecular-based diagnostics
Treatment of prosthetic osteoarticular

Esteban J;Cordero-Ampuero J; 2011 Review
infections
Debate rages over antibiotic prophylaxis

Garg A;Guez G; 2011 Commentary
in patients with total joint replacements
Perioperative, Postoperative, and

Prophylactic Use of Antibiotics in
Mercuri LG;Psutka D; 2011 Alloplastic Total Temporomandibular Survey
Joint Replacement Surgery: A Survey
and Preliminary Guidelines
Significance of sentinel infective events

Swan J;Dowsey M;Babazadeh
2011 in haematogenous prosthetic knee Retrospective study
S;Mandaleson A;Choong PF;
infections
Prophylactic oral antibiotics reduce

Zywiel MG;Johnson AJ;Stroh DA;Martin
2011 reinfection rates following two-stage Retrospective sudy
J;Marker DR;Mont MA;

Development of a novel PCR method to
Akiyama T;Miyamoto H;Fukuda K;Sano
comprehensively analyze salivary Not relevant to bacteremia or
N;Katagiri N;Shobuike T;Kukita 2010
bacterial flora and its application to implant infection evidence
A;Yamashita Y;Taniguchi H;Goto M;
patients with odontogenic infections
Akutsu Y;Matsubara H;Shuto K;Shiratori

Pre-operative dental brushing can reduce
T;Uesato M;Miyazawa Y;Hoshino Not relevant to bacteremia or
2010 the risk of postoperative pneumonia in
I;Murakami K;Usui A;Kano M;Miyauchi implant infection evidence
esophageal cancer patients
H;
de Oliveira CE;Gasparoto TH;Dionisio Candida albicans and denture stomatitis:

Not relevant to bacteremia or
TJ;Porto VC;Vieira NA;Santos CF;Lara 2010 evaluation of its presence in the lesion,
implant infection evidence
VS; prosthesis, and blood
Ebersole JL;Stevens J;Steffen Systemic endotoxin levels in chronic Not relevant to bacteremia or
2010
MJ;Dawson ID;Novak MJ; indolent periodontal infections implant infection evidence
Bebek B;Bago I;Skaljac G;Plecko Antimicrobial effect of 0.2% Not relevant to bacteremia or
2009
V;Miletic I;Anic I; chlorhexidine in infected root canals implant infection evidence
The bacteriology of salivary gland

Brook I; 2009 Review
infections
Empirical antimicrobial therapy for

Herzke CA;Chen LF;Anderson DJ;Choi bloodstream infection due to methicillin- Not relevant to bacteremia or
2009
Y;Sexton DJ;Kaye KS; resistant Staphylococcus aureus: no implant infection evidence
better than a coin toss
Huddleston PM;Clyburn TA;Evans

Surgical site infection prevention and
RP;Moucha CS;Prokuski LJ;Joseph 2009 Review
control: An emerging paradigm
J;Sale K;

Kuong EE;Ng FY;Yan CH;Fang Antibiotic prophylaxis after total joint
2009 Review
CX;Chiu PK; replacements
Cleft soft palate reconstruction:

Myburgh HP;Butow KW; 2009 prospective study on infection and
antibiotics
Serotype classification of Streptococcus

Nakano K;Ooshima T; 2009 mutans and its detection outside the oral Not applicable
cavity
Parahitiyawa NB;Jin LJ;Leung WK;Yam Microbiology of odontogenic bacteremia:

2009 Review
WC;Samaranayake LP; beyond endocarditis
Etiology and outcome of oral mucosal

Anirudhan D;Bakhshi S;Xess I;Broor Not relevant to bacteremia or
2008 lesions in children on chemotherapy for
S;Arya LS; implant infection evidence
acute lymphoblastic leukemia
Bahrani-Mougeot FK;Paster BJ;Coleman Identification of oral bacteria in blood

S;Ashar J;Knost S;Sautter RL;Lockhart 2008 cultures by conventional versus
PB; molecular methods
Bahrani-Mougeot FK;Thornhill M;Sasser Systemic host immuno-inflammatory

H;Marriott I;Brennan MT;Papagerakis 2008 response to dental extractions and
S;Coleman S;Fox PC;Lockhart PB; periodontitis
PCR-based identification of selected

pathogens associated with endodontic Not relevant to bacteremia or
Cogulu D;Uzel A;Oncag O;Eronat C; 2008
infections in deciduous and permanent implant infection evidence
teeth

Oral care and the risk of bloodstream
Jones DJ;Munro CL; 2008 infections in mechanically ventilated Review
adults: A review
Lalani T;Chu VH;Grussemeyer CA;Reed Clinical outcomes and costs among

SD;Bolognesi MP;Friedman JY;Griffiths patients with Staphylococcus aureus
2008 Cost analysis
RI;Crosslin DR;Kanafani ZA;Kaye bacteremia and orthopedic device
KS;Ralph CG;Fowler VG; infections
Effect of ultrasonic debridement using a

chlorhexidine irrigant on circulating Not relevant to bacteremia or
Lee MK;Ide M;Coward PY;Wilson RF; 2008
levels of lipopolysaccharides and implant infection evidence
interleukin-6
Antibiotic prophylaxis before dental

Montefusco V;Gay F;Spina F;Miceli procedures may reduce the incidence of
R;Maniezzo M;Teresa AM;Farina L;Piva 2008 osteonecrosis of the jaw in patients with Retrospective study
S;Palumbo A;Boccadoro M;Corradini P; multiple myeloma treated with
bisphosphonates
Sassone LM;Fidel RA;Faveri M;Guerra A microbiological profile of symptomatic Not relevant to bacteremia or
2008
R;Figueiredo L;Fidel SR;Feres M; teeth with primary endodontic infections implant infection evidence
Assessment of oral status and oro-

Tosello A;Chevaux JM;Montal S;Foti B; 2008 pharyngeal candidosis in elderly in short-
term hospital care
Antibiotic prophylaxis before invasive

Uckay I;Pittet D;Bernard L;Lew
2008 dental procedures in patients with Review
D;Perrier A;Peter R;
arthroplasties of the hip and knee

Wright TI;Baddour LM;Berbari
Antibiotic prophylaxis in dermatologic
EF;Roenigk RK;Phillips PK;Jacobs 2008 Advisory Statement
surgery: advisory statement 2008
MA;Otley CC;
Assessment of febrile neutropenia

Yilmaz S;Oren H;Demircioglu F;Irken G; 2008 episodes in children with acute leukemia Retrospective study
treated with BFM protocols
Antimicrobial susceptibility of 800

Kuriyama T;Williams DW;Yanagisawa
anaerobic isolates from patients with Not relevant to bacteremia or
M;Iwahara K;Shimizu C;Nakagawa 2007
dentoalveolar infection to 13 oral implant infection evidence
K;Yamamoto E;Karasawa T;
antibiotics
Microbiota of the dorsum of the tongue

Faveri M;Feres M;Shibli JA;Hayacibara Not relevant to bacteremia or
2006 after plaque accumulation: An
RF;Hayacibara MM;de Figueiredo LC; implant infection evidence
experimental study in humans
Severe odontogenic infections, part 2: Not relevant to bacteremia or

Flynn TR;Shanti RM;Hayes C; 2006
prospective outcomes study implant infection evidence
Flynn TR;Shanti RM;Levi MH;Adamo Severe odontogenic infections, part 1: Not relevant to bacteremia or
2006
AK;Kraut RA;Trieger N; prospective report implant infection evidence
Autoaggregation and coaggregation of

Khemaleelakul S;Baumgartner Not relevant to bacteremia or
2006 bacteria associated with acute endodontic
JC;Pruksakom S; implant infection evidence
infections
Marculescu CE;Berbari EF;Hanssen Outcome of prosthetic joint infections

AD;Steckelberg JM;Harmsen 2006 treated with debridement and retention of Retrospective study
SW;Mandrekar JN;Osmon DR; components

Prevalence of selected bacterial named
Rocas IN;Baumgartner JC;Xia T;Siqueira species and uncultivated phylotypes in Not relevant to bacteremia or
2006
JF; endodontic abscesses from two implant infection evidence
geographic locations
Identification of bacteria in endodontic

Saito D;Leonardo RT;Rodrigues JL;Tsai Not relevant to bacteremia or
2006 infections by sequence analysis of 16S
SM;Hofling JF;Goncalves RB; implant infection evidence
rDNA clone libraries
Molecular analysis of bacteria in

Sakamoto M;Rocas IN;Siqueira Not relevant to bacteremia or
2006 asymptomatic and symptomatic
JF;Benno Y; implant infection evidence
endodontic infections
Fungal and bacterial infection in

Sakr MR;El-Aiady AA;Ragab Not relevant to bacteremia or
2006 malnourished children and its relation to
SH;Gomaa HE;El Din HG; implant infection evidence
severity of the disease
Sixou JL;Aubry-Leuliette A;De

Medeiros-Battista O;Lejeune S;Jolivet- Capnocytophaga in the dental plaque of
Gougeon A;Solhi-Pinsard H;Gandemer 2006 immunocompromised children with
V;Barbosa-Rogier M;Bonnaure-Mallet cancer
M;
Antibacterial prophylaxis for dental, GI,

Not available 2005 Review
and GU procedures
A study on the polymicrobial etiology of

root canal infections in anterior non-vital Not relevant to bacteremia or
Chakraborty P;Chattopadhyay UK; 2005
teeth in a government hospital in implant infection evidence
Kolkata, India

Identification of cultivable
Chu FC;Tsang CS;Chow microorganisms from primary Not relevant to bacteremia or
2005
TW;Samaranayake LP; endodontic infections with exposed and implant infection evidence
unexposed pulp space
Effect of endodontic procedures on

Ferrari PH;Cai S;Bombana AC; 2005 enterococci, enteric bacteria and yeasts in
primary endodontic infections
Huang ST;Lee HC;Lee NY;Liu KH;Ko Clinical characteristics of invasive

WC; Haemophilus aphrophilus infections
Iwai T;Inoue Y;Umeda M;Huang Oral bacteria in the occluded arteries of Not relevant to bacteremia or
2005
Y;Kurihara N;Koike M;Ishikawa I; patients with Buerger disease implant infection evidence
The effectiveness of preoperative rinsing

Nowak E;Niepsuj K;Nolewajka-Lasak with skinsept oral on reducing the Not relevant to bacteremia or
2005
I;Rheinbaben FV; bacterial flora and eradicating implant infection evidence
Helicobacter pylori in the oral cavity
Shariff G;Brennan MT;Louise KM;Fox Relationship between oral bacteria and Not relevant to bacteremia or
2004
PC;Weinrib D;Burgess P;Lockhart PB; hemodialysis access infection implant infection evidence
Apisarnthanarak A;Mayfield JL;Garison Risk factors for Stenotrophomonas

T;McLendon PM;DiPersio JF;Fraser 2003 maltophilia bacteremia in oncology
VJ;Polish LB; patients: a case-control study
Fusobacterium nucleatum: a rare cause of

Candoni A;Fili C;Trevisan R;Silvestri Not relevant to bacteremia or
2003 bacteremia in neutropenic patients with
F;Fanin R; implant infection evidence
leukemia and lymphoma

Krcmery V;Gogova M;Ondrusova
A;Buckova E;Doczeova A;Mrazova
M;Hricak V;Fischer V;Marks P;Kovacik Etiology and Risk Factors of 339 Cases
J;Schramekova E;Vitekova D;Sedlak of Infective Endocarditis: Report from a
2003 Not applicable
T;Duris I;Samudovsky J;Semanova 10-year National Prospective Survey in
M;Kovac M;Duris T;Herman the Slovak Republic
O;Cernoskova M;Sefara J;Kojsova
M;Baranikova D;Ayazi M;Neuschlova D
Microbial identification in the

Listgarten MA;Loomer PM; 2003 management of periodontal diseases. A Review
systematic review
Antibiotic prophylaxis for patients with

Seymour RA;Whitworth JM;Martin M; 2003 joint prostheses: still a dilemma for Retrospective study
dental practitioners (Brief record)
Aerobic and anaerobic microbiology of Not relevant to bacteremia or

Brook I; 2002
suppurative sialadenitis implant infection evidence
Fouad AF;Barry J;Caimano M;Clawson PCR-based identification of bacteria Not relevant to bacteremia or
2002
M;Zhu Q;Carver R;Hazlett K;Radolf JD; associated with endodontic infections implant infection evidence
Systemic release of endotoxins induced

Geerts SO;Nys M;De MP;Charpentier Not relevant to bacteremia or
2002 by gentle mastication: association with
J;Albert A;Legrand V;Rompen EH; implant infection evidence
periodontitis severity
Kucukkaya M;Kabukcuoglu Y;Tezer Management of childhood chronic tibial Not relevant to bacteremia or
2002
M;Kuzgun U; osteomyelitis with the Ilizarov method implant infection evidence

Molecular and cultural analysis of the
Munson MA;Pitt-Ford T;Chong Not relevant to bacteremia or
2002 microflora associated with endodontic
B;Weightman A;Wade WG; implant infection evidence
infections
Peters LB;Wesselink PR;van Winkelhoff Combinations of bacterial species in Not relevant to bacteremia or
2002
AJ; endodontic infections implant infection evidence
Reebye UN;Ollerhead TR;Hughes The microbial composition of mandibular Not relevant to bacteremia or
2002
CV;Cottrell DA; third molar pericoronal infections implant infection evidence
Intravenous antibiotic regimens and

Roberts G;Holzel H; 2002 Retrospective study
prophylaxis of odontogenic bacteraemia
Sunde PT;Olsen I;Debelian GJ;Tronstad Microbiota of periapical lesions

2002 Not applicable
L; refractory to endodontic therapy
Oral bacteria influenced by the functional

Tada A;Watanabe T;Yokoe H;Hanada Not relevant to bacteremia or
2002 status of the elderly people and the type
N;Tanzawa H; implant infection evidence
and quality of facilities for the bedridden
Cost-effectiveness of antibiotic
van SD;Kaandorp C;Krijnen P; 2002 Cost analysis
prophylaxis for bacterial arthritis
The clinical and microbiological effects

Fernandes-Naglik L;Downes J;Shirlaw
of a novel acidified sodium chlorite Not relevant to bacteremia or
P;Wilson R;Challacombe SJ;Kemp 2001
mouthrinse on oral bacterial mucosal implant infection evidence
GK;Wade WG;
infections

Biochemical and genetic characterization
Fujiwara T;Nakano K;Kawaguchi
of serologically untypable Streptococcus Not relevant to bacteremia or
M;Ooshima T;Sobue S;Kawabata 2001
mutans strains isolated from patients with implant infection evidence
S;Nakagawa I;Hamada S;
bacteremia
Partial spectrum of microorganisms

Glass RT;Bullard JW;Hadley CS;Mix Not relevant to bacteremia or
2001 found in dentures and possible disease
EW;Conrad RS; implant infection evidence
implications
Antibiotic prophylaxis for

Krijnen P;Kaandorp CJ;Steyerberg haematogenous bacterial arthritis in
2001 Cost analysis
EW;van SD;Moens HJ;Habbema JD; patients with joint disease: a cost
effectiveness analysis
Lana MA;Ribeiro-Sobrinho AP;Stehling Microorganisms isolated from root canals

R;Garcia GD;Silva BK;Hamdan 2001 presenting necrotic pulp and their drug
JS;Nicoli JR;Carvalho MA;Farias LM; susceptibility in vitro
Isolation of yeasts and enteric bacteria in

Peciuliene V;Reynaud AH;Balciuniene Not relevant to bacteremia or
2001 root-filled teeth with chronic apical
I;Haapasalo M; implant infection evidence
periodontitis
Efficacy of cetylpyridinium chloride used Not relevant to bacteremia or

Pitten FA;Kramer A; 2001
as oropharyngeal antiseptic implant infection evidence
Clinical presentation, radiological

findings, and treatment results of
Wrobel CJ;Chappell ET;Taylor W; 2001 Retrospective study
coccidioidomycosis involving the spine:
report on 23 cases

Bacteriologic features and antimicrobial
Kuriyama T;Karasawa T;Nakagawa Not relevant to bacteremia or
2000 susceptibility in isolates from orofacial
K;Saiki Y;Yamamoto E;Nakamura S; implant infection evidence
odontogenic infections
Outbreak of Stenotrophomonas
Labarca JA;Leber AL;Kern VL;Territo
maltophilia bacteremia in allogenic bone
MC;Brankovic LE;Bruckner DA;Pegues 2000 n<10
marrow transplant patients: role of severe
DA;
neutropenia and mucositis
Lucht U; 2000 The Danish Hip Arthroplasty Register Review
Presence of microorganisms on the

Monsenego P; 2000 fitting denture complete surface: study 'in
vivo'
Prevalence of periodontal pathogens in

Mullally BH;Dace B;Shelburne Not relevant to bacteremia or
2000 localized and generalized forms of early-
CE;Wolff LF;Coulter WA; implant infection evidence
onset periodontitis
Osaki T;Yoneda K;Yamamoto T;Ueta Candidiasis may induce glossodynia Not relevant to bacteremia or
2000
E;Kimura T; without objective manifestation implant infection evidence
Investigation of infectious organisms

Peltroche-Llacsahuanga H;Reichhart Not relevant to bacteremia or
2000 causing pericoronitis of the mandibular
E;Schmitt W;Lutticken R;Haase G; implant infection evidence
third molar
Comparison of profiles of key

Rupf S;Kannengiesser S;Merte K;Pfister Not relevant to bacteremia or
2000 periodontal pathogens in periodontium
W;Sigusch B;Eschrich K; implant infection evidence
and endodontium

Siqueira JF;Rocas IN;Souto R;de Checkerboard DNA-DNA hybridization Not relevant to bacteremia or
2000
UM;Colombo AP; analysis of endodontic infections implant infection evidence
Extraradicular infection: a Not relevant to bacteremia or

Sunde PT;Olsen I;Lind PO;Tronstad L; 2000
methodological study implant infection evidence
Sunde PT;Tronstad L;Eribe ER;Lind Assessment of periradicular microbiota Not relevant to bacteremia or
2000
PO;Olsen I; by DNA-DNA hybridization implant infection evidence
Antibiotic prophylaxis in orthognathic Not relevant to bacteremia or

Bentley KC;Head TW;Aiello GA; 1999
surgery: a 1-day versus 5-day regimen implant infection evidence
Bacteremia after oral surgery and

Hall G;Heimdahl A;Nord CE; 1999 Review
antibiotic prophylaxis for endocarditis
LaPorte DM;Waldman BJ;Mont Infections associated with dental

MA;Hungerford DS; procedures in total hip arthroplasty
Oral microflora as a cause of endocarditis

Lockhart PB;Durack DT; 1999 Review
and other distant site infections
Nicolatou-Galitis O;Bakiri M;Belegrati Oropharyngeal candidiasis in patients

M;Nikolatos G;Spyropoulos C;Fisfis 1999 with hematological immunosuppression.
M;Kalmantis T;Velegraki A; A pilot study
The diagnostic accuracy of microbiologic

Reit C;Molander A;Dahlen G; 1999 root canal sampling and the influence of
antimicrobial dressings
Invasive Kingella kingae infection Not relevant to bacteremia or

Amir J;Yagupsky P; 1998
associated with stomatitis in children implant infection evidence

Nd:YAG-assisted periodontal curettage
Pinero J; 1998 to prevent bacteria before cardiovascular
surgery
Prolonged suppressive antibiotic therapy

Segreti J;Nelson JA;Trenholme GM; 1998 Retrospective study
for infected orthopedic prostheses

Chaudhry R;Kalra N;Talwar V;Thakur R; 1997 Anaerobic flora in endodontic infections
Role of anaerobic species in endodontic Not relevant to bacteremia or

Drucker DB;Gomes BP;Lilley JD; 1997
infection implant infection evidence
Jacobson J;Patel B;Asher G;Woolliscroft Oral staphylococcus in older subjects Not relevant to bacteremia or
1997
JO;Schaberg D; with rheumatoid arthritis implant infection evidence
Existence of Candida albicans and

Kulak Y;Arikan A;Kazazoglu E; 1997 microorganisms in denture stomatitis
patients
Irradiation of infected root canals with a

Moritz A;Gutknecht N;Schoop Not relevant to bacteremia or
1997 diode laser in vivo: results of
U;Goharkhay K;Doertbudak O;Sperr W; implant infection evidence
microbiological examinations
Total knee arthroplasty infections

Waldman BJ;Mont MA;Hungerford DS; 1997 Retrospective study
associated with dental procedures
Full- versus partial-mouth disinfection in

Bollen CM;Vandekerckhove the treatment of periodontal infections. A Not relevant to bacteremia or
1996
BN;Papaioannou W;Van EJ;Quirynen M; pilot study: long-term microbiological implant infection evidence
observations

Deacon JM;Pagliaro AJ;Zelicof Prophylactic use of antibiotics for
1996 Review
SB;Horowitz HW; procedures after total joint replacement
Electrophoresis of whole-cell soluble

Debelian GJ;Olsen I;Tronstad L; 1996 proteins of microorganisms isolated from
bacteremias in endodontic therapy
Rajasuo A;Jousimies-Somer
Bacteriologic findings in tonsillitis and Not relevant to bacteremia or
H;Savolainen S;Leppanen J;Murtomaa 1996
pericoronitis implant infection evidence
H;Meurman JH;
Yoneyama T;Hashimoto K;Fukuda Oral hygiene reduces respiratory

H;Ishida M;Arai H;Sekizawa K;Yamaya 1996 infections in elderly bed-bound nursing
M;Sasaki H; home patients
Full- vs. partial-mouth disinfection in the

Quirynen M;Bollen CM;Vandekerckhove
treatment of periodontal infections: short- Not relevant to bacteremia or
BN;Dekeyser C;Papaioannou W;Eyssen 1995
term clinical and microbiological implant infection evidence
H;
observations
Richard P;Amador D;Moreau P;Milpied

Viridans streptococcal bacteraemia in Not relevant to bacteremia or
N;Felice MP;Daeschler T;Harousseau 1995
patients with neutropenia implant infection evidence
JL;Richet H;
Relation between mouth and

Bartzokas CA;Johnson R;Jane M;Martin
1994 haematogenous infection in total joint n<10
MV;Pearce PK;Saw Y;
replacements

Effect of treatment on titer, function, and
antigen recognition of serum antibodies
Sjostrom K;Ou J;Whitney C;Johnson Not relevant to bacteremia or
1994 to Actinobacillus
B;Darveau R;Engel D;Page RC; implant infection evidence
actinomycetemcomitans in patients with
rapidly progressive periodontitis
Anaerobic osteomyelitis and arthritis in a Not relevant to bacteremia or

Brook I;Frazier EH; 1993
military hospital: a 10-year experience implant infection evidence
Failure of clindamycin to influence the

course of severe oromucositis associated
Donnelly JP;Muus P;Horrevorts Not relevant to bacteremia or
1993 with streptococcal bacteraemia in
AM;Sauerwein RW;de Pauw BE; implant infection evidence
allogeneic bone marrow transplant
recipients
Changes in the prevalence of subgingival

enteric rods, staphylococci and yeasts Not relevant to bacteremia or
Helovuo H;Hakkarainen K;Paunio K; 1993
after treatment with penicillin and implant infection evidence
erythromycin
Temperature elevation in children

Holan G;Kadari A;Engelhard D;Chosack following dental treatment under general Not relevant to bacteremia or
1993
A; anesthesia with or without prophylactic implant infection evidence
antibiotics
Efficacy of azithromycin compared with

Lo Bue AM;Sammartino R;Chisari Not relevant to bacteremia or
1993 spiramycin in the treatment of
G;Gismondo MR;Nicoletti G; implant infection evidence
odontogenic infections

Changes in the oral microflora during
O'Sullivan EA;Duggal MS;Bailey Not relevant to bacteremia or
1993 cytotoxic chemotherapy in children being
CC;Curzon ME;Hart P; implant infection evidence
treated for acute leukemia
Prevalence of diabetes mellitus in

odontogenic infections and oral Not relevant to bacteremia or
Ueta E;Osaki T;Yoneda K;Yamamoto T; 1993
candidiasis: an analysis of neutrophil implant infection evidence
suppression
Gingival status during chemical plaque

Bergmann OJ;Ellegaard B;Dahl control with or without prior mechanical Not relevant to bacteremia or
1992
M;Ellegaard J; plaque removal in patients with acute implant infection evidence
myeloid leukaemia
Efficacy of chlorhexidine and nystatin

rinses in prevention of oral complications Not relevant to bacteremia or
Epstein JB;Vickars L;Spinelli J;Reece D; 1992
in leukemia and bone marrow implant infection evidence
transplantation
The relationship between clinical

Hashioka K;Yamasaki M;Nakane Not relevant to bacteremia or
1992 symptoms and anaerobic bacteria from
A;Horiba N;Nakamura H; implant infection evidence
infected root canals
Evaluation of new anti-infective drugs

for the treatment of infections of
Norden C;Nelson JD;Mader JT;Calandra
1992 prosthetic hip joints. Infectious Diseases Review
GB;
Society of America and the Food and
Drug Administration
Bacteriological investigation of infected Not relevant to bacteremia or

Ufomata D;Akerele JO; 1992
root canals in Benin City, Nigeria implant infection evidence

Bacteria in the apical 5 mm of infected Not relevant to bacteremia or
Baumgartner JC;Falkler WA; 1991
root canals implant infection evidence
Alterations in oral microflora and

pathogenesis of acute oral infections Not relevant to bacteremia or
Bergmann OJ; 1991
during remission-induction therapy in implant infection evidence
patients with acute myeloid leukaemia
Isolation and classification of anaerobic

Hirai K;Tagami A;Okuda K; 1991 bacteria from pulp cavities of nonvital
teeth in man
Chemoprophylaxis of prosthetic joint

Jacobson JJ;Schweitzer SO;Kowalski CJ; 1991 patients during dental treatment: a Decision utiltiy analysis
decision-utility analysis
Antibiotic prophylaxis during dental

Thyne GM;Ferguson JW; 1991 treatment in patients with prosthetic Review
joints
Antibiotic prophylaxis for the prevention

Bell SM;Gatus BJ;Shepherd BD; 1990 Retrospective study
of late infections of prosthetic joints
Antibiotic prophylaxis for dental patients

Jacobson JJ;Schweitzer S;DePorter
1990 with joint prostheses? A decision Decision utiltiy analysis
DJ;Lee JJ;
analysis
Peterson DE;Minah GE;Reynolds Effect of granulocytopenia on oral

MA;Weikel DS;Overholser CD;DePaola 1990 microbial relationships in patients with
LG;Wade JC;Suzuki JB; acute leukemia

Peripheral teflon catheters. Potential
Wilkins J;Patzakis MJ; 1990 source for bacterial contamination of Irrelevant study population
orthopedic implants?
Oral infections and fever in

Bergmann OJ; 1989 immunocompromised patients with
haematologic malignancies
Oral gram-negative bacilli in bone

Brown AT;Sims RE;Raybould TP;Lillich Not relevant to bacteremia or
1989 marrow transplant patients given
TT;Henslee PJ;Ferretti GA; implant infection evidence
chlorhexidine rinses
Treatment of sequestra, pseudarthroses,

and defects in the long bones of children
Daoud A;Saighi-Bouaouina A; 1989 Retrospective study
who have chronic hematogenous
osteomyelitis
Effect on plaque growth and salivary

Etemadzadeh H;Meurmann
micro-organisms of amine fluoride- Not relevant to bacteremia or
JH;Murtomaa H;Torkko H;Lappi L;Roos 1989
stannous fluoride and chlorhexidine- implant infection evidence
M;
containing mouthrinses
Treatment of severe odontogenic

Gerlach KL;Schaal KP;Walz C;Pape HD; 1989 infections with amoxicillin/clavulanic
acid
The oral cavity as a port of entry for

Heimdahl A;Mattsson T;Dahllof Not relevant to bacteremia or
1989 early infections in patients treated with
G;Lonnquist B;Ringden O; implant infection evidence
bone marrow transplantation

Dental X-ray status of patients admitted Not relevant to bacteremia or
Lindqvist C;Soderholm AL;Slatis P; 1989
for total hip replacement implant infection evidence
Lo Bue AM;Chisari G;Fiorenza G;Ferlito The activity of ofloxacin compared to Not relevant to bacteremia or
1989
S;Gismondo MR; spiramycin in oral surgery implant infection evidence
Steele MT;Sainsbury CR;Robinson Prophylactic penicillin for intraoral Not relevant to bacteremia or
1989
WA;Salomone JA;Elenbaas RM; wounds implant infection evidence
Cost-effectiveness of antibiotic
Tsevat J;Durand-Zaleski I;Pauker SG; 1989 prophylaxis for dental procedures in Cost analysis
patients with artificial joints
Incidence of fever following invasive

Weikel DS;Peterson DE;Rubinstein Not relevant to bacteremia or
1989 oral interventions in the myelosuppressed
LE;Metzger-Samuels C;Overholser CD; implant infection evidence
cancer patient
Reduction of oral flora with Not relevant to bacteremia or

Appelbaum PC;Spangler SK;Strauss M; 1988
ciprofloxacin in healthy volunteers implant infection evidence
Oral infections and septicemia in

Bergmann OJ; 1988 immunocompromised patients with
hematologic malignancies
Total joint replacement: a consideration

Cioffi GA;Terezhalmy GT;Taybos GM; 1988 Review
for antimicrobial prophylaxis
Clinical and microbiological effects of in

De LM; 1988 vivo miocamycin therapy on oral
infections and in surgical prophylaxis

Control of oral mucositis and candidiasis
Ferretti GA;Ash RC;Brown AT;Parr in marrow transplantation: a prospective, Not relevant to bacteremia or
1988
MD;Romond EH;Lillich TT; double-blind trial of chlorhexidine implant infection evidence
digluconate oral rinse
Jacobson JJ;Schweitzer S;DePorter Chemoprophylaxis of dental patients

1988 Simulation model
DJ;Lee JJ; with prosthetic joints: a simulation model
Ranta H;Haapasalo M;Ranta Bacteriology of odontogenic apical

K;Kontiainen S;Kerosuo E;Valtonen 1988 periodontitis and effect of penicillin
V;Suuronen R;Hovi T; treatment
Use of an organic iodine compound to

Rosen S;Ogg-Bell K;Heller Not relevant to bacteremia or
1988 decrease oral microflora in the implant
A;Weisenstein P;Beck FM; implant infection evidence
patient
Short-term antibiotic prophylaxis in

Dumbach J;Spitzer W; 1987 elective oral and maxillofacial surgery
with mezlocillin and oxacillin
Human serum antibody responses to oral

Ebersole JL;Taubman MA;Smith Not relevant to bacteremia or
1987 microorganisms. IV. Correlation with
DJ;Frey DE;Haffajee AD;Socransky SS; implant infection evidence
homologous infection
Concurrent oral surgery and orthopaedic

treatment in the multiply injured patient:
Foster RJ;Collins FJ;Bach AW; 1987 Irrelevant study population
is there an increased incidence of
orthopaedic sepsis?

Bacteria isolated from late prosthetic
Jacobson JJ;Matthews LS; 1987 joint infections: dental treatment and Retrospective study
chemoprophylaxis
Colonization and infection in surgical

Kerver AJH;Rommes JH;Mevissen- Not relevant to bacteremia or
1987 intensive care patients - A prospective
Verhage EAE; implant infection evidence
study
Characterization by pyocine typing and

Komiyama K;Habbick BF;Martin serotyping of oral and sputum strains of Not relevant to bacteremia or
1987
T;Tumber SK; Pseudomonas aeruginosa isolated from implant infection evidence
cystic fibrosis patients
Maniloff G;Greenwald R;Laskin Delayed postbacteremic prosthetic joint

1987 n<10
R;Singer C; infection
Organisms isolated from severe

odontogenic soft tissue infections: Their
Quayle AA;Russell C;Hearn B; 1987 sensitivities to cefotetan and seven other
antibiotics, and implications for therapy
and prophylaxis
Fong IW;Ledbetter WH;Vandenbroucke Ciprofloxacin concentrations in bone and

1986 Not applicable
AC;Simbul M;Rahm V; muscle after oral dosing
Jacobson JJ;Millard HD;Plezia Dental treatment and late prosthetic joint

R;Blankenship JR; infections
Bacteriological status of closed root Not relevant to bacteremia or

Santosh S;Saini OP;Manjit C;Uma S; 1986
canals of non-vital teeth implant infection evidence

Further methodological improvement in
antibiotic bone concentration Not relevant to bacteremia or
Wittmann DH;Kotthaus E; 1986
measurements: penetration of ofloxacin implant infection evidence
into bone and cartilage
Clinical appearance of orofacial

Heimdahl A;von KL;Satoh T;Nord CE; 1985 infections of odontogenic origin in
relation to microbiological findings
Oral trimethoprim sulfamethoxazole for

prevention of bacterial infection during Not relevant to bacteremia or
Kovatch AL;Wald ER;Albo VC; 1985
the induction phase of cancer implant infection evidence
chemotherapy in children
A multicenter, randomized parallel

double-blind study comparing three
Mangini P;Cicchetti M;Bottaro L; 1985 antibiotics, cephemic-cofosfolactamine,
fosfomycin and cephalexin, in the
treatment of systemic infections
Is antibiotic prophylaxis required for

McGowan DA;Hendrey ML; 1985 Retrospective study
dental patients with joint replacements?
Effect of repeated high dose prophylaxis

Woodman AJ;Vidic J;Newman Not relevant to bacteremia or
1985 with amoxycillin on the resident oral
HN;Marsh PD; implant infection evidence
flora of adult volunteers
Serum amoxycillin levels following oral

Cannon PD;Black HJ;Kitson K;Ward CS; 1984 loading dose prior to outpatient general
anaesthesia for dental extractions

Newman MG; 1984 Anaerobic oral and dental infection Review
The asplenic patient: a consideration for

Terezhalmy GT;Hall EH; 1984 Review
antimicrobial prophylaxis
Streptococci isolated from the Not relevant to bacteremia or

Crawford I;Russell C; 1983
bloodstream and gingival crevice of man implant infection evidence
Continued evolution of the microbiology Not relevant to bacteremia or

Hunt DE;Meyer RA; 1983
of oral infections implant infection evidence
Resistance in oral streptococci after

Southall PJ;Mahy NJ;Davies RM;Speller Not relevant to bacteremia or
1983 repeated two-dose amoxycillin
DC; implant infection evidence
prophylaxis
Ornidazole compared to
von KL;Nord CE; 1983 phenoxymethylpenicillin in the treatment
of orofacial infections
An investigation to determine the

Erasmus M;Lichter D;Rock R;Rumbak Not relevant to bacteremia or
1982 frequency of resistance of plaque bacteria
A;Rumbak J; implant infection evidence
to certain antimicrobial drugs
Greenberg MS;Cohen SG;McKitrick The oral flor as a source of septicemia in Not relevant to bacteremia or
1982
JC;Cassileth PA; patients with acute leukemia implant infection evidence
The value of the bacteriological culture

Stobberinoh EE;Eggink CO; 1982 in endodontics. II. The bacteriological
flora of endodontic specimens

Bacteriologic evaluation of the efficacy
Bystrom A;Sundqvist G; 1981 of mechanical root canal instrumentation
in endodontic therapy
Lessons learned from surveillance

cultures in patients with acute
Newman KA;Schimpff SC;Young Not relevant to bacteremia or
1981 nonlymphocytic leukemia. Usefulness for
VM;Wiernik PH; implant infection evidence
epidemiologic, preventive and
therapeutic research
Anaerobic bacteria in dentoalveolar Not relevant to bacteremia or

von KL;Nord CE;Nordenram A; 1981
infections implant infection evidence
Prophylactic coverage of dental patients

with artificial joints: a retrospective
Jacobsen PL;Murray W; 1980 Retrospective study
analysis of thirty-three infections in hip
prostheses
Kannangara DW;Thadepalli H;McQuirter Bacteriology and treatment of dental Not relevant to bacteremia or
1980
JL; infections implant infection evidence
Relationship between bacterial

Krekmanov L;Hallander HO; 1980 contamination and alveolitis after third
molar surgery
Prophylactic antibiotics against early and

Carlsson AK;Lidgren L;Lindberg L; 1977 late deep infections after total hip Retrospective study
replacements
The microbiology of dentalpyogenic Not relevant to bacteremia or

Sabiston CB;Grigsby WR; 1977

Effect of two antimicrobial rinses and
Altonen M;SAXEN L;Kosunen Not relevant to bacteremia or
1976 oral prophylaxis on preoperative
T;Ainamo J; implant infection evidence
degerming of saliva
Asymptomatic orophyarngeal flora in Not relevant to bacteremia or

Billick SB;Borchardt KA;Poenisch P; 1976
patients admitted to hospital implant infection evidence

Williams BL;Pantalone RM;Sherris JC; 1976 Subgingival microflora and periodontitis
Antibiotic efficacy in odontogenic Not relevant to bacteremia or

Gabrielson ML;Stroh E; 1975
Streptococcus faecalis and Streptococcus

faecium in infected dental root canals at
Mejare B; 1975 filling and their susceptibility to
azidocillin and some comparable
antibiotics
Microscopic and baceriologic analysis of Not relevant to bacteremia or

Murray PR;Washington JA; 1975
expectorated sputum implant infection evidence

Sabiston CB;Gold WA; 1974 Anaerobic bacteria in oral infections
The clinical bacteriology of purulent oral Not relevant to bacteremia or

Sims W; 1974
Prevalence and antibiotic susceptibility

Turner JE;Mincer HH; 1974 of microorganisms isolated from oral
infectious disease

Stone HH;Geheber CE;Kolb Alimentary tract colonization by Candida Not relevant to bacteremia or
1973
LD;Kitchens WR; albicans implant infection evidence
Bacteroides corrodens isolated from

Khairat O; 1967 Duplicate publication
bacteriaemias
Bacteremia and oral sepsis with

Diener J;Schwartz SM;Shelanski particular reference to the possible Not relevant to bacteremia or
1964
M;Steinberg G; reduction of systemic disease originating implant infection evidence
from the oral cavity
The risks of dental extraction during Not relevant to bacteremia or

Garrod LP;WATERWORTH PM; 1962
penicillin treatment implant infection evidence

APPENDIX IV
MEDICAL LIBRARIAN SEARCH STRATEGY
PUBMED/MEDLINE STRATEGY:
#1
Dentistry[mh] OR Mouth[mh] OR "Dental Care"[mh] OR "Mouth Diseases/therapy"[mh] OR
"Mouth Neoplasms/therapy"[mh] OR "Dental implants"[mh] OR "Dental Prosthesis"[mh] OR
"Nonodontogenic Cysts"[mh] OR "Odontogenic Cysts"[mh] OR "Dental Health Surveys"[mh]
OR "oral bacteria" OR "dental caries" OR ((oral[titl] OR dental[titl]) NOT medline[sb]) OR
"Teeth Extraction"[ot] OR Tooth[ot] OR Dentistry[ot] OR Endodontics[ot] OR jsubsetd
#2
flossing[tiab] OR toothbrush*[tiab] OR brushing[tiab] OR dental[tiab] OR oral[tiab] OR
periodont*[tiab] OR endodont*[tiab] OR gingiv*[tiab] OR mouth[tiab] OR hematogenous[tiab]
#3
"Bacterial Infections"[mh:noexp] OR Bacteremia[mh] OR Fungemia[mh] OR bacteremia[tiab]
OR bacteraemia[tiab] OR fungemia[tiab] OR fungaemia[tiab] OR (Septicemia[mh:noexp] AND
1966[mhda]:1991[mhda]) OR Bacteremia[ot] OR "Streptococcal Infections"[ot] OR
Septicemia[ot]
#4
"Anti-bacterial agents"[pa] OR "Anti-bacterial agents"[mh] OR "Antifungal Agents"[mh] OR
"Anti-Infective Agents, Local"[mh] OR "Anti-Infective Agents"[mh:noexp] OR
(Premedication[mh] AND 1973[mhda]:1995[mhda]) OR "Antibiotic Prophylaxis"[mh] OR
("Postoperative Complications"[mh] AND " Anti-bacterial agents/therapeutic use"[mh] AND
1968[mhda]:1975[mhda]) OR (antibiotic*[tiab] AND prophyla*[tiab]) OR "Prosthesis-Related
Infections"[mh] OR Infection Control[mh] OR (Infection[mh:noexp] AND
1966[mhda]:1991[mhda])
#5
"Prostheses and Implants"[mh:noexp] OR "Bone Nails"[mh] OR "Bone Plates"[mh] OR "Bone
Screws"[mh] OR "Internal Fixators"[mh] OR "Joint Prosthesis"[mh] OR Arthroplasty[mh] OR
arthroplasty[tiab] OR ((joint[tiab] OR knee[tiab] OR hip[tiab]) AND (artificial[tiab] OR
replacement[tiab] OR prosthe*[tiab])) OR (("Tissue Scaffolds"[mh] OR instrumentation[tiab]
OR rod[tiab] OR rods[tiab] OR allograft*[tiab] OR "bone glass" OR (bone[tiab] AND void[tiab]
AND filler*[tiab])) AND "Orthopedic Procedures"[mh]) OR "Bone Transplantation"[mh] OR
("Prosthesis Implantation"[mh] OR (silastic[tiab] AND (implant*[tiab] OR prosthes*[tiab]))
AND ("Musculoskeletal System"[mh] OR Extremities[mh]))
#6
#1 AND #3
#7
#5 AND (#4 OR #3) AND (#2 OR #1)

#8
#6 OR #7
#9
English[lang]
#10
(animal[mh] NOT human[mh]) OR cadaver[mh] OR cadaver*[titl] OR ((comment[pt] OR
editorial[pt] OR letter[pt] OR "historical article"[pt]) NOT "clinical trial"[pt]) OR addresses[pt]
OR news[pt] OR "newspaper article"[pt] OR pmcbook
#11
#8 AND #9 NOT #10
Results sorted by study type
#12
Medline[tw] OR systematic review[tiab] OR Meta-analysis[pt]
#13
"Clinical Trial"[pt] OR (clinical[tiab] AND trial[tiab]) OR random*[tw] OR "Therapeutic
use"[sh]
#14
#11 AND #12
#15
#11 AND #13 NOT #12
#16
#11 NOT (#13 OR #12)
EMBASE SEARCH STRATEGY

#1
Dentistry/exp OR Mouth/exp OR 'Dental Care'/exp OR 'mouth
disease'/dm_dt,dm_su,dm_th,dm_rh,dm_dm OR 'mouth
tumor'/dm_dt,dm_su,dm_th,dm_rh,dm_dm OR 'odontogenic cyst'/de OR 'odontogenic
keratocyst'/de OR 'odontogenic tumor'/de
#2
flossing:ti,ab OR toothbrush*:ti,ab OR dental:ti,ab OR peridont*:ti,ab OR endodont*:ti,ab OR
gingiv*:ti,ab OR mouth:ti,ab OR hematogenous:ti,ab OR 'oral bacteria'
#3
'Bacterial Infection'/de OR Bacteremia/exp OR Fungemia/exp OR bacteremia:ti,ab OR
bacteraemia:ti,ab OR fungemia:ti,ab OR fungaemia:ti,ab

#4
'Antiinfective Agent'/exp OR 'Antibiotic Prophylaxis'/de OR 'antibiotic prophylaxis' OR
'Prosthesis Infection'/de OR Infection/de
#5
'Joint Prosthesis'/exp OR 'Bone Nail'/de OR 'Bone Plate'/de OR 'Bone Screw'/de OR 'Internal
Fixator'/de OR 'Pedicle Screw'/de OR 'Bone Graft'/exp OR 'tissue scaffold'/de OR 'bone void
filler' OR ('silicone prosthesis'/de AND 'musculoskeletal system'/exp)
#6
#1 AND #3
#7
#5 AND (#4 OR #3) AND (#2 OR #1)
#8
#6 OR #7
#9
English:la AND [humans]/lim AND [embase]/lim
#10
cadaver/de OR 'in vitro study'/exp OR 'abstract report'/de OR book/de OR editorial/de OR
note/de OR (letter/de NOT 'types of study'/exp)
#11
#8 AND #9 NOT #10
#12
'meta analysis':ti,ab,de OR 'systematic review':ti,ab,de OR medline:ti,ab,de
#13
random*:ti,ab,de OR 'clinical trial':ti,ab,de OR 'health care quality'/exp
#14
#11 AND #12
#15
(#11 AND #13) NOT #12
#16
#11 NOT (#12 OR #13)

COCHRANE LIBRARY STRATEGY
(dental OR periodont* OR gingiv* OR mouth) AND (bacteremia OR bacteraemia OR fungemia
OR fungaemia)
SUPPLEMENTAL SEARCH
PUBMED/MEDLINE
#1
"Prostheses and Implants"[mh:noexp] OR "Bone Nails"[mh] OR "Bone Plates"[mh] OR "Bone
Screws"[mh] OR "Internal Fixators"[mh] OR "Joint Prosthesis"[mh] OR Arthroplasty[mh] OR
arthroplasty[tiab] OR ((joint[tiab] OR knee[tiab] OR hip[tiab]) AND (artificial[tiab] OR
replacement[tiab] OR prosthe*[tiab])) OR (("Tissue Scaffolds"[mh] OR instrumentation[tiab]
OR rod[tiab] OR rods[tiab] OR allograft*[tiab] OR "bone glass" OR (bone[tiab] AND void[tiab]
AND filler*[tiab])) AND "Orthopedic Procedures"[mh]) OR "Bone Transplantation"[mh] OR
("Prosthesis Implantation"[mh] OR (silastic[tiab] AND (implant*[tiab] OR prosthes*[tiab]))
AND ("Musculoskeletal System"[mh] OR Extremities[mh]))
#2
Bacteremia[mh] OR Fungemia[mh] OR bacteremia[tiab] OR bacteraemia[tiab] OR
fungemia[tiab] OR fungaemia[tiab] OR hematogenous[tiab] OR haematogenous[tiab] OR "late
infection" OR (late[titl] AND infection[titl])
#3
#1 AND #2
#4
"1960"[PDat]:"2011"[PDat] AND English[lang]
#5
(animal[mh] NOT human[mh]) OR cadaver[mh] OR cadaver*[titl] OR ((comment[pt] OR
editorial[pt] OR letter[pt] OR "historical article"[pt]) NOT "clinical trial"[pt]) OR case
reports[pt] OR addresses[pt] OR news[pt] OR "newspaper article"[pt] OR pmcbook
#6
#3 AND #4 NOT #5
#7
Medline[tw] OR systematic review[tiab] OR Meta-analysis[pt]
#8 (removed "therapeutic use"[sh] from published filter search string)

"Clinical Trial"[pt] OR (clinical[tiab] AND trial[tiab]) OR random*[tw]
#9 (added keywords for joint registries)

cohort studies[mh] OR cohort* OR (epidemiologic methods[mh:noexp] AND
1966[pdat]:1989[pdat]) OR case-control studies[mh] OR ((case OR cases) AND (control OR

controls OR controlled)) OR ((case OR cases) AND series*) OR registr* OR register*
#10
Microbiological Techniques[mh]
#11
#6 AND #7
#12
#6 AND #8 NOT #7
#13
#6 AND #9 NOT (#7 OR #8)
#14
#6 AND #10 NOT (#7 OR #8 OR #9)
#15
#6 NOT (#7 OR #8 OR #9 OR #10)
EMBASE
#1
Arthroplasty/exp OR 'Joint Prosthesis'/exp OR 'Bone Nail'/de OR 'Bone Plate'/de OR 'Bone
Screw'/de OR 'Internal Fixator'/de OR 'Pedicle Screw'/de OR 'Bone Graft'/exp OR 'tissue
scaffold'/de OR 'bone void filler' OR ('silicone prosthesis'/de AND 'musculoskeletal system'/exp)
#2
Bacteremia/exp OR Fungemia/exp OR bacteremia:ti,ab OR bacteraemia:ti,ab OR fungemia:ti,ab
OR fungaemia:ti,ab
#3
#1 AND #2
#4
English:la AND [humans]/lim AND [embase]/lim
#5
cadaver/de OR 'in vitro study'/exp OR 'abstract report'/de OR book/de OR editorial/de OR
note/de OR (letter/de NOT 'types of study'/exp)
#6
#3 AND #4 NOT #5

#7
'meta analysis':ti,ab,de OR 'systematic review':ti,ab,de OR medline:ti,ab,de
#8
random*:ti,ab,de OR 'clinical trial':ti,ab,de OR 'health care quality'/exp
#9
'cohort analysis'/exp OR 'longitudinal study'/exp OR 'prospective study'/exp OR 'follow up'/exp
OR cohort* OR 'case control study'/exp OR (case* AND control*)
#10
'microbiological examination'/exp
#11
#6 AND #7
#12
#6 AND #8 NOT #7
#13
#6 AND #9 NOT (#7 OR #8)
#14
#6 AND #10 NOT (#7 OR #8 OR #9)
#15
#6 NOT (#7 OR #8 OR #9 OR #10)

APPENDIX V
EVALUATING QUALITY AND APPLICABILITY
STUDIES OF INTERVENTIONS
QUALITY
We judged quality using questions specified before this topic was selected and a computer
program determined the final quality rating. We separately evaluated the quality of evidence for
each outcome reported by each study. This follows the suggestion of the GRADE working
group. We evaluated quality using a domain-based approach using a scheme to allow for
evaluation of intervention studies of all designs. The domains we used are whether:
 The study was prospective (with prospective studies, it is possible to have an a priori
hypothesis to test; this is not possible with retrospective studies.)
 The study was of low statistical power
 The assignment of patients to groups was unbiased
 There was blinding to mitigate against a placebo effect
 The patient groups were comparable at the beginning of the study
 The intervention was delivered in such a way that any observed effects could reasonably
be attributed to that intervention
 Whether the instruments used to measure outcomes were valid
Each quality domain is addressed by one or more questions that are answered “Yes,” ”No,” or
“Unclear.” These questions and the domains that each address are shown below.
To arrive at the quality of the evidence for a given outcome, all domains except the “Statistical
Power” domain are termed as “flawed” if one or more questions addressing any given domain
are answered “No” for a given outcome, or if there are two or more “Unclear” answers to the
questions addressing that domain. The “Statistical Power” domain is considered flawed if a given
study did not enroll enough patients to detect a standardized difference between means of 0.2.
Domain flaws lead to corresponding reductions in the quality of the evidence. The manner in
which we conducted these reductions is shown in the table below. For example, the evidence
reported in a randomized controlled trial (RCT) for any given outcome is rated as “High” quality
if zero or one domain is flawed. If two or three domains are flawed for the evidence addressing
this outcome, the quality of evidence is reduced to “Moderate,” and if four or five domains are
flawed, the quality of evidence is reduced to “Low.” The quality of evidence is reduced to “Very
Low” if six or more domains are flawed.
Some flaws are so serious that we automatically term the evidence as being of “Very Low”
quality, regardless of a study’s domain scores. These serious design flaws are:
 Non-consecutive enrollment of patients in a case series

 Case series that gave patients the treatment of interest AND another treatment
 Measuring the outcome of interest one way in some patients and measuring it in another
way in other patients
 Low statistical power

Quality Questions and Domains for Four Designs of Studies of Interventions
Parallel,
Contemporary Crossover Historical Case
Domain Question: Controls Trials Controls Series
Group Assignment Stochastic Yes Yes No No
Group Assignment Quasi-random Assignment No No No na*
Group Assignment Matched Groups No No Yes No
Group Assignment Consecutive Enrollment na na na Yes
Prospective Prospective Yes Yes Yes Yes
Blinding Blinded Patients Yes Yes No No
Blinding Blinded Assessors Yes Yes No No
Blinding Blinding Verified Yes Yes No No
Group Comparability Allocation Concealment Yes Yes No No
Group Comparability >80% Follow-up Yes Yes No Yes
Group Comparability <20% Completion Difference Yes Yes No No
Group Comparability Similar Baseline Outcome Values Yes na Yes No
Group Comparability Comparable Pt. Characteristics Yes na Yes No
Group Comparability Same Control Group Results na Yes na na
Group Comparability Same Experimental Group Results na Yes na na
Treatment Integrity Same Centers Yes Yes Yes No
Same Treatment Duration in and
Treatment Integrity
across All Groups Yes Yes Yes No
Same Concomitant Treatment to All
Treatment Integrity
Groups (controlled studies only) Yes Yes Yes na
No Confounding Treatment (case
Treatment Integrity
series only) na na na Yes
Measurement Same Instruments Yes Yes Yes Yes
Measurement Valid Instrument Yes Yes Yes Yes
Bias Article & Abstract Agree Yes Yes Yes Yes
Bias All Outcomes Reported Yes Yes Yes Yes
Bias A Priori Analysis Yes Yes Yes Yes
Statistical Power Statistically Significant High High High High
Statistical Power Number of patients in analysis See below for further information
*”na” means “not asked”
Relationship between Quality and Domain Scores for Studies of Interventions

Number of Flawed Domains Strength of Evidence
0-1 High
2-3 Moderate
4-5 Low
>5 Very Low
APPLICABILITY
We rated the applicability (also called “generalizability” or “external validity”) of the evidence
for each outcome reported by each study. As with quality, a computer program that used
predetermined questions about specific applicability domains determined applicability ratings.
We rated applicability as either “High”, “Moderate”, or “Low” depending on how many domains
are flawed. As with quality, a domain is “flawed” if one or more questions addressing that
domain is answered “No: or if two or more are answered “Unclear.” We characterized a domain
as “flawed” if one or more questions addressing any given domain are answered “No” for a

given outcome, or if there are two or more “Unclear” answers to the questions addressing that
domain
Our questions and domains about applicability are those of the PRECIS instrument. The
instrument was originally designed to evaluate the applicability of randomized controlled trials,
but it can also be used for studies of other design. The questions in this instrument fall into four
domains. These domains and their corresponding questions are shown below. The applicability
of a study is rated as “High” if it has no flawed domains, as “Low” if all domains are flawed, and
as “Moderate” in all other cases as shown in the table below.
Applicability Questions and Domains for Studies of Interventions

Question Domain
All Types of Patients Enrolled Participants
Flexible Instructions to Practitioners Interventions and Expertise
Full Range of Expt'l Practitioners Interventions and Expertise
Usual Practice Control Interventions and Expertise
Full Range of Control Practitioners Interventions and Expertise
No Formal Follow-up Interventions and Expertise
Usual and Meaningful Outcome Interventions and Expertise
Compliance Not Measured Compliance and Adherence
No Measure of Practitioner Adherence Compliance and Adherence
All Patients in Analysis Analysis
Relationship between Applicability and Domain Scores for Interventions

0 High
1, 2, 3 Moderate
4 Low

STUDIES OF INCIDENCE AND PREVALENCE
QUALITY
Our appraisal of studies of incidence and prevalence is a domain-based approach conducted
using a priori questions and scored by a computer program. The four domains we employed are:
 Outcome (whether the study is measuring the incidence/prevalence of a clinically

meaningful event)
 Measurement (whether the study measured the disease/disorder/condition in a way that
would lead to accurate estimates of incidence or prevalence)
 Participants (whether those who were studied were representative of the population of
interest)
 Investigator Bias (whether author biases could have prejudiced the results)
Quality Questions and Domains for Studies of Incidence and Prevalence

Question Domain Incidence Prevalence
Outcome Could Occur >1 Time in a Participant None* Yes Yes
Study of Proportions or Number of Episodes None Yes Yes
Only First Episode Counted Measurement Yes Yes
Standard Methods for Collecting Outcomes Data Outcome Yes Yes
Consistent Outcome Definitions Outcome Yes Yes
Data Obtained from People or Records None Yes Yes
Free from Response Bias Measurement Yes Yes
Free from Information Bias Measurement Yes Yes
Valid Instrument Measurement Yes Yes
Valid Database Entries Measurement Yes Yes
Study of In-Hospital Events None Yes Yes
Use of Medical Records/Administrative Databases Measurement Yes Yes
Appropriately Timed Outcome Measurement Yes No
Chronic or Acute Disease None No Yes
Study of Point Prevalence None No Yes
Can Estimate Be Affected by Disease Severity None Yes Yes
Correction for Disease Severity Measurement Yes Yes
Population or Sample Data None Yes Yes
Random Selection of Participants Participants Yes Yes
>80% of Patients in Analysis Participants Yes Yes
Free of Financial Conflicts of Interest Bias Yes Yes
A Priori Analysis Bias Yes Yes
Consistent Abstract, Results, Discussion Bias Yes Yes
*An entry of “None” means that the question is not used in determining quality but, rather, is used for
other purposes. A “Yes” entry in the above table means that a question is asked, a “No” entry means that
it is not asked.
We characterized a study that has no flaws in any of its domains as being of “High” quality, a
study that has one flawed domain as being of “Moderate” quality, a study with two flawed
domains as being of “Low” quality, and a study with three or more flawed domains as being of
“Very Low” quality. We characterized a domain as “flawed” if one or more questions addressing
any given domain are answered “No” for a given screening/diagnostic/test, or if there are two or
more “Unclear” answers to the questions addressing that domain.

We considered some design flaws as so serious that their presence automatically guarantees that
a study is characterized as being of “Very Low” quality regardless of its domain scores. These
flaws are:
 The outcome of interest could have occurred more than once in a person during the
course of the study, and more than the first episode of the outcome was counted in the
incidence/prevalence estimate
 The study was a study of the proportion (or number) of people who have a disease, and
the study was not a study of point prevalence.
Relationship between Quality and Domain Scores for Studies of Incidence and Prevalence
0 High
1 Moderate
2 Low
≥3 Very Low
APPLICABILITY
We separately evaluated the applicability of prevalence and incidence studies, and did so using a
domain-based approach that involves predetermined questions and computer scoring. The
domains we used for the applicability of prognostics are:
 Participants (i.e. whether the participants in the study were like those seen in the
population of interest)
 Analysis (i.e., whether participants were appropriately included and excluded from the
analysis)
 Outcome (i.e., whether the incidence/prevalence estimates being made were of a
clinically meaningful outcome)
Applicability Questions and Domains for Studies of Incidence and Prevalence

Question Domain
Full Spectrum of Patients Patients
All Patients in Analysis Patients
No Stepwise Analysis Analysis
Unambiguous Coding Scheme Analysis
Model Validated Analysis
Clinically Meaningful Outcome Outcome
We characterized a domain as “flawed” if one or more questions addressing any given domain
are answered “No” for a given screening/diagnostic/test, or if there are two or more “Unclear”
answers to the questions addressing that domain. We characterized the applicability of a
screening/diagnostic test as “High” if none of its domains are flawed, “Low” if all of its domains
are flawed, and “Moderate” in all other cases.

Relationship between Applicability and Domain Scores for Studies of Incidence and
Prevalence
0 High
1,2 Moderate
3 Low

STUDIES OF PROGNOSTICS
QUALITY
Our appraisal of studies of prognostics is a domain-based approach conducted using a priori
questions, and scored by a computer program. The five domains we employed are:
 Prospective (A variable is specified as a potential prognostic variable a priori. This is not

possible with retrospective studies.)
 Power (Whether the study had sufficient statistical power to detect a prognostic variable
as statistically significant)
 Analysis (Whether the statistical analyses used to determine that a variable was rigorous
to provide sound results)
 Model (Whether the final statistical model used to evaluate a prognostic variable
accounted for enough variance to be statistically significant)
Quality Questions and Domains for Studies of Prognostics

Question Domain
Prospective Prospective
At Least 10 Patients per Important Variable Power
At Least 10 Events* Power
All Important Variables Screened for Entry Into Model Analysis
Interactions Tested Analysis
Collinearity Absent Analysis
Primary Analysis (not subgroup or post hoc) Analysis
Statistically Significant Fit Model
Article and Abstract Agree Investigator Bias
Results Reported for All Variables Studies Investigator Bias
Blinded Data Analysts** Investigator Bias
*Asked only if the variable predicted by the prognostic is dichotomous.
**Asked only if the prognostic variable is derived from a study that attempts to predict which patients
respond best to a treatment.
We separately determined a quality score for each prognostic reported by a study. We

characterized the evidence relevant to that prognostic variable as being of “High” quality if there
are no flaws in any of the relevant domains, as being of “Moderate” quality if one of the relevant
domains is flawed, as “Low” quality if there are two flawed domains, and as “Very Low” quality
if three or more relevant domains are flawed. We characterized a domain as “flawed” if one or
more questions addressing any given domain are answered “No” for a given prognostic variable,
or if there are two or more “Unclear” answers to the questions addressing that domain.
Relationship between Quality and Domain Scores for Studies of Prognostics

0 High
1 Moderate
2 Low
≥3 Very Low

APPLICABILITY
We separately evaluated the applicability of each prognostic variable reported in a study, and did
so using a domain-based approach that involves predetermined questions and computer scoring.
The domains we used for the applicability of prognostics are:
 Patients (i.e. whether the patients in the study and in the analysis were like those seen in
actual clinical practice)
 Analysis (i.e., whether the analysis was not conducted in a way that was likely to describe
variation among patients that might be unique to the dataset the authors used)
 Outcome (i.e., whether the prognostic was a predictor of a clinically meaningful
outcome)
Applicability Questions and Domains for Studies of Prognostics

Question Domain
Full Spectrum of Patients Patients
All Patients in Analysis Patients
No Stepwise Analysis Analysis
Unambiguous Coding Scheme Analysis
Model Validated Analysis
Clinically Meaningful Outcome Outcome
We characterized the evidence relevant to that prognostic as being of “High” applicability if

there are no flaws in any of the relevant domains, as being of “Low” applicability if all three
domains are flawed, and as of “Moderate” applicability in all other cases. We characterized a
domain as “flawed” if one or more questions addressing any given domain are answered “No”
for a given prognostic variable, or if there are two or more “Unclear” answers to the questions
addressing that domain.
Relationship between Domain Scores and Applicability for Studies of Prognostics

0 High
1,2 Moderate
3 Low

APPENDIX VI
RULES FOR OPINION BASED CONSENSUS RECOMMENDATIONS
A guideline can contain recommendations that are backed by little or no data. Under such
circumstances, work groups often issue opinion-based recommendations. Although doing so is
sometimes acceptable in an evidence-based guideline (expert opinion is a form of evidence), it is
also important to avoid constructing a guideline that liberally uses expert opinion; research
shows that expert opinion is often incorrect.
Opinion-based recommendations are developed only if they address a vitally important aspect of
patient care. For example, constructing an opinion-based recommendation in favor of taking a
history and physical is warranted. Constructing an opinion-based recommendation in favor of a
specific modification of a surgical technique is seldom warranted. To ensure that an opinion-
based recommendation is absolutely necessary, the AAOS has adopted rules to guide the content
of the rationales that underpin such recommendations. These rules are based on those outlined by
the US Preventive Services Task Force (USPSTF).27 Specifically, rationales based on expert
opinion must:
 Not contain references to or citations from articles not included in the systematic review
that underpins the recommendation.
 Not contain the AAOS guideline language “We Recommend”, “We suggest” or “The
practitioner might”.
 Contain an explanation of the potential preventable burden of disease. This involves

considering both the incidence and/or prevalence of the disease, disorder, or condition
and considering the associated burden of suffering. To paraphrase the USPSTF, when
evidence is insufficient, provision of a treatment (or diagnostic) for a serious condition
might be viewed more favorably than provision of a treatment (or diagnostic) for a
condition that does not cause as much suffering. The AAOS (like the USPSTF)
understand that evaluating the “burden of suffering” is subjective and involves judgment.
This evaluation should be informed by patient values and concerns. The considerations
outlined in this bullet make it difficult to recommend new technologies. It is not
appropriate for a guideline to recommend widespread use of a technology backed by little
data and for which there is limited experience.
 Address potential harms. In general, “When the evidence is insufficient, an intervention

with a large potential for harm (such as major surgery) might be viewed less favorably
than an intervention with a small potential for harm (such as advice to watch less
television).”27
 Address apparent discrepancies in the logic of different recommendations. Accordingly,

if there are no relevant data for several recommendations and the work group chooses to
issue an opinion-based recommendation in some cases but chooses not to make a
recommendation in other cases, the rationales for the opinion-based recommendations
must explain why this difference exists. Information garnered from the previous bullet
points will be helpful in this regard.

 Consider current practice. The USPSTF specifically states that clinicians justifiably fear
that not doing something that is done on a widespread basis will lead to litigation.27 The
consequences of not providing a service that is neither widely available nor widely used
are less serious than the consequences of not providing a treatment accepted by the
medical profession and thus expected by patients. Discussions of available treatments and
procedures rely on mutual communication between the patient’s guardian and physician,
and on weighing the potential risks and benefits for a given patient. The patient’s
“expectation of treatment” must be tempered by the treating physician’s guidance about
the reasonable outcomes that the patient can expect.
 Justify, why a more costly device, drug, or procedure is being recommended over a less
costly one whenever such an opinion-based recommendation is made.
Work group members write the rationales for opinion based recommendations on the first day of
the final work group meeting. When the work group re-convenes on the second day of its
meeting, it will vote on the rationales. The typical voting rules will apply. If the work group
cannot adopt a rationale after three votes, the rationale and the opinion-based recommendation
will be withdrawn, and a “recommendation” stating that the group can neither recommend for or
against the recommendation in question will appear in the guideline.
Discussions of opinion-based rationales may cause some members to change their minds about
whether to issue an opinion-based recommendation. Accordingly, at any time during the
discussion of the rationale for an opinion-based recommendation, any member of the work group
can make a motion to withdraw that recommendation and have the guideline state that the work
group can neither recommend for or against the recommendation in question.
CHECKLIST FOR VOTING ON CONSENSUS RECOMMENDATIONS

1. When voting on the rationale, please consider the following:
2. Does the recommendation affect a substantial number of patients or address treatment (or
diagnosis) of a condition that causes death and/or considerable suffering?
3. Does the recommendation address the potential harms that will be incurred if it is
implemented and, if these harms are serious, does the recommendation justify;
a. why the potential benefits outweigh the potential harms and/or
b. why an alternative course of treatment (or diagnostic workup) that involves less
serious or fewer harms is not being recommended?
4. Does the rationale explain why the work group chose to make a recommendation in the face
of minimal evidence while, in other instances, it chose to make no recommendation in the
face of a similar amount of evidence?
5. Does the rationale explain that the recommendation is consistent with current practice?
6. If relevant, does the rationale justify why a more costly device, drug, or procedure is being
recommended over a less costly one?

APPENDIX VII
VOTING WITH THE NOMINAL GROUP TECHNIQUE
Voting on guideline recommendations will be conducted using a modification of the nominal
group technique (NGT), a method previously used in guideline development.28 Briefly each
member of the guideline Work Group ranks his or her agreement with a guideline
recommendation on a scale ranging from 1 to 9 (where 1 is “extremely inappropriate” and 9 is
“extremely appropriate”). Consensus is obtained if the number of individuals who do not rate a
measure as 7, 8, or 9 is statistically non-significant (as determined using the binomial
distribution). Because the number of Work Group members who are allowed to dissent with the
recommendation depends on statistical significance, the number of permissible dissenters varies
with the size of the work group. The number of permissible dissenters for several work group
sizes is given in the table below:
Number of Permissible
Group Size Dissenters
<4 group size not allowed
4-5 0
6-8 1
9-11 1
12-14 2
15-16 3
17-19 4
20-22 5
23-24 6
25-27 7
28-29 8
30-32 9
33-34 10
35-36 11
The NGT is conducted by first having members vote on a given recommendation without
discussion. If the number of dissenters is “permissible”, the recommendation is adopted without
further discussion. If the number of dissenters not permissible, there is further discussion to see
whether the disagreement(s) can be resolved. Three rounds of voting are held to attempt to
resolve disagreements. If disagreements are not resolved after three voting rounds, no
recommendation is adopted.

APPENDIX VIII
STRUCTURED PEER REVIEW FORM
Review of any AAOS confidential draft allows us to improve the overall guideline but does not imply endorsement by any
given individual or any specialty society who participates in our review processes. The AAOS review process may result in
changes to the documents; therefore, endorsement cannot occur until the AAOS Board of Directors officially approves the
final guideline. The ADA will also employ a formal approval process.
Please note that if you return a review:

 Your review comments will be published on the AAOS website, and may be published on the ADA website, with our
explanation of why we did or did not change the draft document in response to your comments.
 Your conflicts of interest disclosures will be published on the AAOS website, and may be published on the ADA
website, with your review comments.
Reviewer Information:
Name of Reviewer:
Address:
City: State: Zip Code:
Phone: Fax: E-mail:
Specialty Area/Discipline:
Work setting: Credentials:
May we list you as a Peer Reviewer in the final Guidelines? Yes No

PLEASE READ: If you do not wish to be listed, your name will be removed for identification purposes.
However, your review comments, our responses and your COI will still be available for
public review on our website with the posted Guideline if you complete this review.
Are you reviewing this guideline as a representative of a professional society? Yes No
If yes, may we list your society as a reviewer of this guideline? Yes No
Society Name:
(Listing the specialty society as a reviewing society does not imply or otherwise indicate endorsement of this guideline.)
Conflicts of Interest (COI): All Reviewers must declare their conflicts of interest.
If the boxes below are not checked and/or the reviewer does not attach his/her conflicts of interest, the reviewer’s comments will not
be addressed by the AAOS nor will the reviewer’s name or society be listed as a reviewer of this GL. If a committee reviews the
guideline, only the chairperson or lead of the review must declare their relevant COI.
I have declared my conflicts of interest on page 2 of this form.
I have declared my conflicts of interest in the AAOS database; my customer # is
I understand that the AAOS will post my declared conflicts of interest with my comments concerning review of
this guideline on the AAOS website.

REVIEWER CONFLICT OF INTEREST - The Orthopaedic Disclosure Program
Each item below requires an answer. Please report information for the last 12-months.
Do you or a member of your immediate family receive royalties for any pharmaceutical, biomaterial or Yes No
orthopaedic product or device?
If YES, please identify product or device:
Within the past twelve months, have you or a member of your immediate family served on the speakers Yes No
bureau or have you been paid an honorarium to present by any pharmaceutical, biomaterial or
orthopaedic product or device company?
If YES, please identify company:
Are you or a member of your immediate family a PAID EMPLOYEE for any pharmaceutical, Yes No
biomaterial or orthopaedic device or equipment company, or supplier?
If YES, please identify company or supplier:
Are you or a member of your immediate family a PAID CONSULTANT for any pharmaceutical, Yes No
Are you or a member of your immediate family an UNPAID CONSULTANT for any pharmaceutical, Yes No
Do you or a member of your immediate family own stock or stock options in any pharmaceutical, Yes No
biomaterial or orthopaedic device or equipment company, or supplier (excluding mutual funds)
Do you or a member of your immediate family receive research or institutional support as a principal
investigator from any pharmaceutical, biomaterial or orthopaedic device or equipment company, or Yes No
supplier?
Do you or a member of your immediate family receive any other financial or material support from any Yes No
pharmaceutical, biomaterial or orthopaedic device and equipment company or supplier?
Do you or a member of your immediate family receive any royalties, financial or material support from Yes No
any medical and/or orthopaedic publishers?
If YES, please identify publisher:
Do you or a member of your immediate family serve on the editorial or governing board of any medical Yes No
and/or orthopaedic publication?
If YES, please identify:
Do you or a member of your immediate family serve on the Board of Directors or a committee of any Yes No
medical and/or orthopaedic professional society?
If YES, please identify:
243
Structured Peer Review Form Instructions
Please read and review this Draft Clinical Practice Guideline with particular focus on your area of expertise. Your responses will be
used to assess the validity, clarity and accuracy of the interpretation of the evidence. If applicable, please specify the draft page and
line numbers in your comments. Please feel free to also comment on the overall structure and content of the document. If you need
more space than is provided, please attach additional pages.
Please complete and return this form electronically in WORD format to [email protected]; please contact Kevin Boyer at (847) 384-
4328 if you have any questions. Thank you in advance for your time in completing this form and giving us your feedback. We value
your input and greatly appreciate your efforts. Please return the completed form in WORD format by end of day March 15, 2012.
Please indicate your level of agreement with each of the following statements by placing an “X” in the appropriate box.
Somewhat Somewhat
Disagree Disagree Agree Agree
1. The recommendations are clearly stated
2. There is an explicit link between the recommendations and the supporting

evidence
3. Given the nature of the topic and the data, all clinically important outcomes
are considered
4. The guideline’s target audience is clearly described
5. The patients to whom this guideline is meant to apply are specifically

described
6. The criteria used to select articles for inclusion are appropriate
7. The reasons why some studies were excluded are clearly described
8. All important studies that met the article inclusion criteria are included
9. The validity of the studies is appropriately appraised
10. The methods are described in such a way as to be reproducible.
11. The statistical methods are appropriate to the material and the objectives of
this guideline
12. Important parameters (e.g., setting, study population, study design) that
could affect study results are systematically addressed
13. Health benefits, side effects, and risks are adequately addressed
14. The writing style is appropriate for health care professionals.
15. The grades assigned to each recommendation are appropriate
244
COMMENTS
PLEASE RETURN ALL COMMENTS IN WORD FORMAT
Please provide a brief explanation of both your positive and negative answers in the preceding section. If applicable, please specify the
draft page and line numbers in your comments. Please feel free to also comment on the overall structure and content of the Guideline
OVERALL ASSESSMENT
Would you recommend these guidelines for use in clinical practice? (Check one)
Strongly recommend
Recommend (with provisions or alterations)
Would not recommend
Unsure
Note: Your answer to this question does not constitute an endorsement of this guideline. We ask this question as a
means of monitoring the clinical relevance of our guideline.
245
APPENDIX IX
PEER REVIEW
Participation in the AAOS-ADA peer review process does not constitute an endorsement of
this guideline by the participating organization.
Peer review of the draft guideline is completed by external organizations with an interest in the
guideline. Outside peer reviewers are solicited for each AAOS guideline and consist of experts in
the guideline’s topic area. These experts represent professional societies other than AAOS and
are nominated by the guideline work group prior to beginning work on the guideline. For this
guideline, twenty-one outside peer review organizations were invited to review the draft
guideline and all supporting documentation. Nine societies participated in the review of this
guideline draft and seven explicitly consented to be listed as a peer review organization in this
appendix. Two organizations did not give explicit consent that the organization name could be
listed in this publication.
The organizations that reviewed the document and consented to be listed as a peer review
organization are listed below:
American Academy of Family Physicians (AAFP)

American Association of Hip and Knee Surgeons (AAHKS)
American Association of Oral and Maxillofacial Surgeons (AOMS)
American Academy of Oral Pathology (AAOP)
American Academy of Pediatric Dentistry (AAPD)
American Association of Public Health Dentistry (AAPHD)
American Dental Association (ADA)
American Dental Hygienists’ Association (ADHA)
Canadian Dental Association (CDA)
Infectious Disease Society of America (IDSA)
Lumbar Spine Research Society (LSRS)
North American Spine Society (NASS)
College of American Pathologists (CAP)
American Academy of Periodontology (AAP)
American College of Prosthodontists (ACP)
Society of Infectious Disease Pharmacists (SIDP)
Individuals who participated in the peer review of this document and gave their consent to be
listed as reviewers of this document are:
Robert Rich, Jr. MD

Brian J. McGrory, MD
Louis G. Mercuri, DDS, MS
Sook-Bin Woo, DMD
A. Charles Post, DDS
Paul A. Moore, DMD, PhD, MPH
Paul S. Farsai, DMD, MPH
Denise Bowers, RDH, PhD
Charles Shuler, DMD, PhD
246
Susan Sutherland, DDS, MSc
John S. Kirkpatrick, MD, MS
Charles A. Reitman, MD
James M. Horton, MD
Tushar Patel, MD
Jamie Baisden, MD, FACS
John Steele, MD, PhD
Frank Scannaapieco, DMD, PhD
Mijin Choi, DDS, MS, FACP
Erika J. Ernst PharmD, BCPS
Participation in the AAOS-ADA guideline peer review process does not constitute an
endorsement of the guideline by the participating organizations or the individuals listed
above nor does it in any way imply the reviewer supports this document.
247
PUBLIC COMMENTARY
A period of public commentary follows the peer review of the draft guideline. If significant non-
editorial changes are made to the document as a result of public commentary, these changes are
also documented and forwarded to the AAOS and ADA bodies that approve the final guideline.
Public commentators who gave explicit consent to be listed in this document include the
following:
Arlen D. Hanssen, MD
Thomas K. Fehring, MD
Laura MB Gehrig, MD
Marc M. DeHart, MD
Participation in the AAOS-ADA guideline public commentary review process does not
constitute an endorsement of the guideline by the participating organizations or the
individual listed nor does it in any way imply the reviewer supports this document.
248
APPENDIX X
AAOS BODIES THAT APPROVED THIS CLINICAL PRACTICE GUIDELINE
Guidelines Oversight Committee
The AAOS Guidelines Oversight Committee (GOC) consists of sixteen AAOS members. The
overall purpose of this Committee is to oversee the development of the clinical practice
guidelines, performance measures, health technology assessments and utilization guidelines.
Evidence Based Practice Committee

The AAOS Evidence Based Practice Committee (EBPC) consists of ten AAOS members. This
Committee provides review, planning, and oversight for all activities related to quality
improvement in orthopaedic practice, including, but not limited to evidence-based guidelines,
performance measures, and outcomes..
Council on Research and Quality

To enhance the mission of the AAOS, the Council on Research and Quality promotes the most
ethically and scientifically sound basic, clinical, and translational research possible to ensure the
future care for patients with musculoskeletal disorders. The Council also serves as the primary
resource to educate its members, the public, and public policy makers regarding evidenced-based
medical practice, orthopaedic devices and biologics regulatory pathways and standards
development, patient safety, occupational health, technology assessment, and other related areas
of importance.
Board of Directors
The 16 member AAOS Board of Directors manages the affairs of the AAOS, sets policy, and
determines and continually reassesses the Strategic Plan.
ADA BODIES THAT APPROVED THIS CLINICAL PRACTICE GUIDELINE
Council on Scientific Affairs
The Council on Scientific Affairs (CSA) consists of seventeen ADA members. The CSA serves
the public, the dental profession and other health professions as the primary source of timely,
relevant and emerging information on the science of dentistry and promotion of oral health.
The CSA provides recommendations to the ADA’s policymaking bodies on scientific issues. The
Council also promotes, reviews, evaluates, and conducts studies on scientific matters.
249
DOCUMENTATION OF APPROVAL
AAOS-ADA Work Group Draft Completed: February 12, 2012
Peer Review Completed: March 15, 2012
Public Commentary Completed: August 27, 2012
AAOS Guidelines Oversight Committee: September 22, 2012
AAOS Evidence Based Practice Committee: September 22, 2012
AAOS Council on Research and Quality: October 26, 2012
AAOS Board of Directors: December 7, 2012
ADA Council on Scientific Affairs November 13, 2012
250
APPENDIX XI
SUPPLEMENTAL EVIDENCE TABLES
Table 59 Antibiotic Prophylaxis Network Meta-Analysis Consistency Check
Direct
MC Direct SD (Ln SD
Comparison Mean MC SD Ln OR OR) Omega Omega Z p
Placebo vs:
Amoxicillin -2.638 0.465 -2.375 0.420 -1.174 0 0.000 1.00
Penicillin -1.738 0.695 -1.266 0.486 -0.451 0 0.000 1.00
Erythromycin -0.852 0.664 -0.669 0.512 -0.267 0 0.000 1.00
Clindamycin -1.453 0.650 -2.112 0.462 0.672 0 0.000 1.00
Josamycin -0.187 1.114 0.228 0.677 -0.243 0 0.000 1.00
Moxifloxacin -2.676 0.961 -2.957 0.765 0.485 0 0.000 1.00
IV Tetracycline -4.123 1.144 -4.075 0.635 -0.022 0 0.000 1.00
IM Teicoplanin -2.312 1.343 -2.674 1.570 -1.347 3.030 0.444 0.66
Topical
Amoxicillin -1.118 1.217 -2.064 1.174 12.797 0 0.000 1.00
Antiseptic Rinse -1.424 1.048 -0.989 0.494 -0.124 0 0.000 1.00
Amoxicillin vs:
Penicillin 0.900 0.731 -0.003 0.600 1.862 0 0.000 1.00
Clindamycin 1.185 0.725 1.892 0.467 -0.503 0 0.000 1.00
Moxifloxacin -0.038 0.959 0.421 0.377 -0.084 0 0.000 1.00
IM Teicoplanin 0.327 1.299 0.811 0.913 -0.472 0 0.000 1.00
Topical
Amoxicillin 1.521 1.215 2.436 1.170 -11.541 0 0.000 1.00
Penicillin vs:
Antiseptic Rinse 0.314 1.06 -0.161 0.568 0.191 0 0.000 1.00
Erythromycin vs:
Clindamycin -0.601 0.696 -0.357 0.568 -0.484 0 0.000 1.00
Josamycin 0.665 1.113 0.228 0.677 0.257 0 0.000 1.00
IV Tetracycline -3.271 1.148 -2.996 0.670 -0.142 0 0.000 1.00
Clindamycin vs:
Moxifloxacin -1.223 0.994 -1.470 0.465 0.069 0 0.000 1.00
251
Table 60 Topical Antimicrobial Prophylaxis Network Meta-Analysis Consistency Check
Direct
Direct SD
MC MC Ln (Ln SD
Mean SD OR OR) Omega Omega Z p
No Treatment vs:
Saline Rinse -0.04 0.45 -0.25 0.58 -0.54 0.93 0.58 0.56
Chlorhexidine Rinse -1.77 0.52 -1.52 0.51 -13.16 0.00 0.00 1.00
Povidone-Iodine Rinse -1.94 0.53 -1.47 0.68 1.24 1.09 1.14 0.26
Chloramine T Rinse/Brush -1.84 0.90 -1.74 0.61 -0.09 0.00 0.00 1.00
Lugol's Solution Rinse -0.30 1.00 -0.27 0.74 -0.03 0.00 0.00 1.00
Hydrogen Peroxide Rinse -1.10 0.56 -0.97 0.35 -0.08 0.00 0.00 1.00
Sodium Perborate-Ascorbic Acid
Rinse -1.75 0.71 -1.56 0.42 -0.10 0.00 0.00 1.00
Phenolated Rinse -1.53 0.51 -1.65 0.53 -1.76 2.05 0.86 0.39
Saline Rinse vs:

Chlorhexidine Rinse -1.73 0.60 -2.49 0.76 -1.96 1.22 1.60 0.11
Sodium Perborate-Ascorbic Acid
Rinse -1.71 0.74 -1.92 0.55 0.27 0.00 0.00 1.00
Phenolated Rinse -1.49 0.59 -1.37 0.40 -0.10 0.00 0.00 1.00
Chlorhexidine Rinse vs:

Hydrogen Peroxide Rinse 0.67 0.64 0.41 0.64 22.85 0.00 0.00 1.00
Placebo Rinse 0.85 0.53 0.47 0.40 0.51 0.00 0.00 1.00
Povidone-Iodine Rinse vs:

Hydrogen Peroxide Rinse 0.84 0.65 0.62 0.65 17.68 0.00 0.00 1.00
Placebo Rinse 1.03 0.51 1.12 0.35 -0.09 0.00 0.00 1.00
Operative Field Isolation -0.89 0.79 -0.87 0.47 -0.02 0.00 0.00 1.00
Isolation + Iodine Rinse -1.02 0.79 -0.98 0.48 -0.02 0.00 0.00 1.00
Isolation + Chlorhexidine Rinse -2.20 0.87 -2.10 0.58 -0.08 0.00 0.00 1.00
Chloramine T Rinse/Brush vs:

Lugol's Solution Rinse 1.54 0.87 1.47 0.57 0.06 0.00 0.00 1.00
Operative Field Isolation vs:

Isolation + Iodine Rinse -0.12 0.79 -0.12 0.49 0.00 0.00 0.00 1.00
Isolation + Iodine Rinse vs:

252
Table 61 Goodness-of-fit Statistics
Data Points Residual Deviance
Antibiotic Prophylaxis Network 43 43.03
Topical Antimicrobial Prophylaxis Network 33 31.31
Table 62 Antibiotic and Topical Antimicrobial Prophylaxis Network Meta-Analysis

Consistency Check
Direct
Direct SD
MC MC Ln (Ln Direct SD
Mean SD OR OR) Var Omega Omega Z p
Placebo Pill/No Treatment
vs:
Amoxicillin -2.56 0.37 -2.38 0.42 0.18 0.81 0.89 0.91 0.36
Penicillin -1.68 0.57 -1.27 0.49 0.24 -1.09 0.00 0.00 1.00
Erythromycin -0.85 0.53 -0.67 0.51 0.26 -3.21 0.00 0.00 1.00
Clindamycin -1.44 0.51 -2.11 0.46 0.21 2.82 0.00 0.00 1.00
Josamycin -0.18 0.91 0.23 0.68 0.46 -0.50 0.00 0.00 1.00
Moxifloxacin -2.61 0.74 -2.96 0.77 0.59 -5.85 3.13 1.87 0.06
IV Tetracycline -4.13 0.95 -4.07 0.63 0.40 -0.04 0.00 0.00 1.00
IM Teicoplanin -2.16 1.16 -2.67 1.57 2.47 -1.12 2.32 0.48 0.63
Topical Amoxicillin -1.07 1.02 -2.06 1.17 1.38 -4.14 2.40 1.72 0.08
Chlorhexidine or Povidone-
Iodine Rinse -1.38 0.83 -0.99 0.49 0.24 -0.22 0.00 0.00 1.00
Saline Rinse -0.01 0.50 -0.80 0.36 0.13 0.80 0.00 0.00 1.00
Chlorhexidine Rinse -1.78 0.57 -1.52 0.51 0.26 -1.16 0.00 0.00 1.00
Povidone-Iodine Rinse -1.93 0.59 -1.47 0.68 0.46 1.83 1.35 1.36 0.17
Chloramine T Rinse/Brush -1.84 0.96 -1.74 0.61 0.38 -0.07 0.00 0.00 1.00
Lugol's Solution Rinse -0.29 1.06 -0.27 0.74 0.55 -0.01 0.00 0.00 1.00
Hydrogen Peroxide Rinse -1.11 0.62 -0.97 0.35 0.12 -0.06 0.00 0.00 1.00
Phenolated Rinse -1.52 0.57 -1.65 0.53 0.28 0.85 0.00 0.00 1.00
Sodium Perborate-Ascorbic
Acid Rinse -1.76 0.79 -1.56 0.42 0.17 -0.08 0.00 0.00 1.00
Amoxicillin vs:
Penicillin 0.88 0.60 0.00 0.60 0.36 507.16 0.00 0.00 1.00
Clindamycin 1.12 0.57 1.89 0.47 0.22 -1.55 0.00 0.00 1.00
Moxifloxacin -0.05 0.73 0.42 0.38 0.14 -0.17 0.00 0.00 1.00
IM Teicoplanin 0.39 1.12 0.81 0.91 0.83 -0.81 0.00 0.00 1.00
Topical Amoxicillin 1.48 1.02 2.44 1.17 1.37 4.03 2.41 1.68 0.09
253
Direct
Direct SD
Penicillin vs:
Chlorhexidine or Povidone-
Iodine Rinse 0.30 0.85 -0.16 0.57 0.32 0.37 0.00 0.00 1.00
Erythromycin vs:
Clindamycin -0.59 0.56 -0.36 0.57 0.32 11.20 3.94 2.84 0.00
Josamycin 0.67 0.91 0.23 0.68 0.46 0.55 0.00 0.00 1.00
IV Tetracycline -3.28 0.96 -3.00 0.67 0.45 -0.27 0.00 0.00 1.00
Clindamycin vs:
Moxifloxacin -1.17 0.77 -1.47 0.46 0.22 0.17 0.00 0.00 1.00
Saline Rinse vs:

Chlorhexidine Rinse -1.77 0.65 -2.49 0.76 0.58 -2.66 1.47 1.81 0.07
Phenolated Rinse -1.51 0.66 -1.37 0.40 0.16 -0.08 0.00 0.00 1.00
Sodium Perborate-Ascorbic
Acid Rinse -1.75 0.82 -1.92 0.55 0.30 0.14 0.00 0.00 1.00
Chlorhexidine Rinse vs:

Hydrogen Peroxide Rinse 0.67 0.70 0.41 0.64 0.41 1.25 0.00 0.00 1.00
Placebo Rinse 0.88 0.58 0.47 0.40 0.16 0.37 0.00 0.00 1.00
Povidone-Iodine Rinse vs:

Hydrogen Peroxide Rinse 0.82 0.71 0.62 0.65 0.42 0.91 0.00 0.00 1.00
Placebo Rinse 1.03 0.56 1.12 0.35 0.13 -0.07 0.00 0.00 1.00
Operative Field Isolation -0.90 0.87 -0.87 0.47 0.22 -0.01 0.00 0.00 1.00
Isolation + Iodine Rinse -1.02 0.87 -0.98 0.48 0.23 -0.01 0.00 0.00 1.00
Isolation + Chlorhexidine
Rinse -2.20 0.94 -2.10 0.58 0.34 -0.06 0.00 0.00 1.00
Chloramine T Rinse/Brush
vs:
Lugol's Solution Rinse 1.55 0.94 1.47 0.57 0.33 0.05 0.00 0.00 1.00
Operative Field Isolation vs:

Isolation + Iodine Rinse -0.12 0.88 -0.12 0.49 0.24 0.00 0.00 0.00 1.00
Rinse -1.31 0.95 -1.23 0.59 0.35 -0.05 0.00 0.00 1.00
254
Direct
Direct SD
Isolation + Iodine Rinse vs:

Rinse -1.18 0.95 -1.11 0.59 0.35 -0.04 0.00 0.00 1.00
Table 63 Bacteremia Incidence Study Details

Study Procedure N n Rate LowerCI UpperCI SD
Bhanji 2002 brushing 47 29 0.617021 0.474266 0.742093 0.068325
Forner 2006 brushing 60 2 0.033333 0.009189 0.113638 0.026646
Lockhart 2008 brushing 88 28 0.318182 0.230226 0.421348 0.048756
Sconyers 1973 brushing 30 5 0.166667 0.073365 0.335644 0.066909
Sconyers 1979 brushing 50 0 0 0 0.071348 0.018202
Forner 2006 chewing 60 4 0.066667 0.026229 0.159254 0.033936
Murphy 2006 chewing 21 0 0 0 0.154639 0.03945
dental
Pineiro 2010 implants 30 2 0.066667 0.018477 0.213235 0.049684
Cherry 2007 prophylaxis 60 11 0.333333 0.218739 0.544864 0.05922
De Leo 1974 prophylaxis 39 11 0.282051 0.165435 0.437753 0.06947
Forner 2006 prophylaxis 19 21 0.35 0.241678 0.476374 0.100626
Forner 2006 prophylaxis 20 15 0.75 0.531299 0.888138 0.091032
Heimdahl
1990 prophylaxis 20 14 0.7 0.481027 0.854523 0.095281
Baumgartner
1976 endodontics 30 1 0.033333 0.005909 0.166704 0.04102
Baumgartner
1977 endodontics 12 7 0.583333 0.319511 0.80674 0.124295
Bender 1963 endodontics 98 15 0.153061 0.095007 0.237289 0.036297
Heimdahl
1990 endodontics 20 4 0.2 0.080658 0.416017 0.085552
Savarrio 2004 endodontics 30 9 0.3 0.166647 0.478758 0.079621
Bender 1963 extraction 33 17 0.515152 0.352184 0.67496 0.082342
Casolari 1989 extraction 56 38 0.678571 0.548226 0.78599 0.060655
Heimdahl
1990 extraction 20 20 1 0.838875 1 0.041105
Khairat 1966 extraction 100 64 0.64 0.542354 0.727288 0.047178
Rahn 1994 injection 40 21 0.525 0.374974 0.670645 0.075428
American
Academy of
Periodontology interdental
1972 cleaner 60 17 0.283333 0.185068 0.407673 0.056788
interdental
Berger 1974 cleaner 30 8 0.266667 0.141827 0.44448 0.077209
interdental
Crasta 2009 cleaner 59 24 0.40678 0.29089 0.534066 0.062036
255
interdental
Felix 1971 cleaner 30 15 0.5 0.331541 0.668459 0.08595
Lineberger interdental
1973 cleaner 30 8 0.266667 0.141827 0.44448 0.077209
interdental
Ramadan 1975 cleaner 50 9 0.18 0.097702 0.307961 0.053638
interdental
Romans 1971 cleaner 30 2 0.066667 0.049684
interdental
Wank 1976 cleaner 21 6 0.285714 0.138139 0.499564 0.092202
Ali 1992 intubation 36 0 0.111111 0.044066 0.253148 0.053338
Berry 1973 intubation 50 4 0.08 0.03155 0.188382 0.040009
Dinner 1987 intubation 54 3 0.055556 0.019073 0.151072 0.033674
Hansen 1989 intubation 19 1 0.052632 0.009352 0.246387 0.060469
Oncag 2005 intubation 74 9 0.121622 0.065323 0.215266 0.038251
Valdes 2008 intubation 110 13 0.118182 0.070381 0.19175 0.030962
Enabulele
2008 oral surgery 50 16 0.32 0.207582 0.458103 0.063909
Heimdahl
1990 oral surgery 20 11 0.55 0.342085 0.741802 0.10197
Josefsson 1985 oral surgery 20 11 0.55 0.342085 0.741802 0.10197
Takai 2005 oral surgery 57 33 0.578947 0.449801 0.698124 0.063349
Erverdi 1999 orthodontics 40 3 0.075 0.025836 0.198642 0.044084
Gürel 2009 orthodontics 25 8 0.32 0.172052 0.515897 0.087717
periodontics
scaling root
Bender 1963 planing 15 8 0.533333 0.30117 0.751905 0.114985
periodontics
scaling root
Casolari 1989 planing 42 12 0.285714 0.17167 0.435672 0.067349
periodontics
scaling root
Lafaurie 2007 planing 42 34 0.809524 0.666992 0.90018 0.059488
periodontics
scaling root
Lofthus 1991 planing 10 3 0.3 0.107791 0.603222 0.126387
periodontics
Lucartorto scaling root
1992 planing 41 13 0.317073 0.195646 0.469842 0.069949
periodontics
Morozumi scaling root
2010 planing 10 9 0.9 0.59585 0.982124 0.098541
periodontics
scaling root
Waki 1990 planing 15 2 0.133333 0.037361 0.37882 0.087108
periodontics
Bender 1963 gingivectomy 12 10 0.833333 0.551969 0.953035 0.102314
Lineberger periodontics
1973 gingivectomy 10 6 0.6 0.312674 0.83182 0.132437
256
periodontics
Rogosa 1960 gingivectomy 13 12 0.923077 0.66686 0.98629 0.081489
periodontics
Wada 1968 gingivectomy 77 20 0.25974 0.174892 0.367422 0.049116
periodontics
Daly 1997 probing 30 13 0.433333 0.273775 0.608027 0.08527
periodontics
Daly 2001 probing 40 10 0.25 0.141871 0.40194 0.066345
Oncag 2006 restorative 23 3 0.130435 0.045377 0.321275 0.070383
Brown 1998 suture 24 2 0.083333 0.023159 0.258488 0.060034
King 1988 suture 20 1 0.05 0.008881 0.236131 0.057973
Wampole 1978 suture 20 5 0.25 0.111862 0.468701 0.091032
Table 64 Bacteremia Prevalence Study Details

Lucas 2000 brushing 52 20 0.384615 0.264705 0.520401 0.06523
Silver 1979 brushing 36 3 0.083333 0.028749 0.218267 0.048347
Degling 1972 chewing 40 0 0 0 0.087622 0.022353
Trivedi 1984 chewing 20 2 0.1 0.027866 0.301034 0.069687
Marzoni 1983 cleft palate 14 6 0.428571 0.213808 0.674094 0.117421
Lucas 1999 prophylaxis 103 33 0.320388 0.238131 0.415562 0.045264
Trivedi 1984 prophylaxis 40 22 0.55 0.398291 0.692947 0.075169
Winslow 1960 prophylaxis 72 17 0.236111 0.152967 0.345988 0.049241
Debelian 1995 endodontics 26 11 0.423077 0.255444 0.610514 0.09058
Barbosa 2010 extraction 210 149 0.709524 0.644796 0.766723 0.031104
Coulter 1990 extraction 32 20 0.625 0.452544 0.770661 0.081154
Crawford
1973 extraction 25 23 0.92 0.750339 0.97778 0.058022
DeVries 1972 extraction 100 49 0.49 0.39422 0.58652 0.049057
Khairat 1966 extraction 100 64 0.64 0.542354 0.727288 0.047178
Maskell 1986 extraction 10 10 1 0.722467 1 0.070801
Peterson 1976 extraction 80 39 0.4875 0.381079 0.595067 0.05459
Roberts 1992 extraction 229 84 0.366812 0.307068 0.430951 0.031603
Roberts 1987 ( extraction 47 18 0.382979 0.257907 0.525734 0.068325
Shanson 1987 extraction 40 13 0.325 0.200845 0.479823 0.071169
Shanson 1978 extraction 20 14 0.7 0.481027 0.854523 0.095281
Tomas 2007 extraction 53 51 0.962264 0.872457 0.98959 0.029881
Trivedi 1984 extraction 40 35 0.875 0.738879 0.945405 0.052686
Roberts 1998 injection 93 49 0.526882 0.42637 0.625261 0.050738
Roberts 1997 intubation 31 3 0.096774 0.033465 0.248999 0.054984
oral surgery
Martin 1964 extraction 50 27 0.54 0.403989 0.670303 0.067939
oral surgery
Rajasuo 2004 extraction 16 14 0.875 0.639772 0.965023 0.082974
oral surgery
Roberts 1998 extraction 103 51 0.495146 0.400516 0.590125 0.04837
oral surgery
Tomas 2008 extraction 100 67 0.67 0.573053 0.754369 0.046255
257
oral surgery
Roberts 1997 flap elevation 51 20 0.392157 0.270273 0.529148 0.066041
oral surgery
Roberts 1998 flap elevation 51 22 0.431373 0.305012 0.567347 0.066923
oral surgery
Rajasuo 2004 plate removal 10 6 0.6 0.312674 0.83182 0.132437
Burden 2004 orthodontics 30 4 0.133333 0.053097 0.296813 0.062174
Degling 1972 orthodontics 10 0 0 0 0.277533 0.070801
periodontics
Kinane 2005 probing 30 5 0.166667 0.073365 0.335644 0.066909
Table 65 Results of Bacteremia Incidence Random Effects Meta-Analysis

Pooled
n Incidence 95% Confidence
Procedure Group studies of Bacteremia* Interval I2
Brushing 5 21.8% 5.2 – 38.4% 96.3%
Chewing 2 3.6% 0 – 10.1% 39.1%
Prophylaxis 5 47.7% 29.0 – 66.4% 85.8%
Endodontics 5 22.1% 8.8 – 35.5% 83.4%
Extraction 4 71.4% 49.4 – 93.4% 94.1%
Interdental Cleaners 8 27.5% 17.8% - 37.1% 77.2%
Intubation 6 9.3% 6.1% - 12.5% 0.0%
Oral Surgery - Extraction 4 49.2% 35.2 – 63.3% 68.9%
Orthodontics 2 18.6% 0 - 42.5% 83.9%
Periodontics – Scaling/Root Planing 7 46.9% 24.4 – 69.4% 92.6%
Periodontics – Gingivectomy 4 65.1% 27.6 – 100% 95.2%
Periodontics – Probing 2 33.4% 15.5 - 51.3% 65.3%
Sialography 2 10.6% 0 – 33.4% 88.5%
Suture 3 10.8% 0.7 – 21% 43.4%

Table 66 Results of Bacteremia Prevalence Random Effects Meta-Analysis
Procedure Group n Pooled 95% I2
258
studies Incidence Confidence
of Bacteremia* Interval
Brushing 2 23.1% 0 – 52.6% 92.7%
Chewing 2 2.8% 0 – 11.6% 46.4%
Prophylaxis 3 35.9% 20.5 – 51.3% 83.6%
Extraction 13 65.3% 51.8 – 78.8% 96.1%
Oral Surgery – Extraction 4 63.7% 49.3 – 78.0% 83.9%
Oral Surgery – Flap Elevation 2 41.2% 31.9 – 50.4% 0.0%
Orthodontics 2 7.1% 0 - 20.1% 50.1%
Restorative – Drilling 2 14.7% 1.4 – 28.0% 84.5%

Restorative – Rubber Dam and Matrix
2 45.6% 18.2 – 73.0% 93.9%
Band & Wedge
259
Table 67 Antibiotic Prophylaxis Studies Not Included in Recommendation 1 Network Meta-analysis
Control (%,
Procedure Study N Strength Outcome (specific type) Active Antibiotic (%, n/N) n/N) Results
Dental No Treatment Favors
Prophylaxis Baltch 1982 56 Low Bacteremia Penicillin G (10.7%, 3/28) (60.7%, 17/28) Penicillin G
Lockhart Placebo (18%, Favors
Intubation 2004 100 High Bacteremia Amoxicillin (4%, 2/49) 9/51) Amoxicillin
Ofloxacin (40%,10/25)
Clindamycin ( 40%, 10/25) Placebo (44%,
Oral Surgery Goker 1992 100 Moderate Bacteremia Sultamicillin (36%, 9/25) 11/25) No difference
Josefsson Penicillin (50%, 10/20) No treatment
Oral Surgery 1985 60 Moderate Bacteremia Erythromycin (55%, 11/20) (55%, 11/20) No difference
IV Cefuroxime (4%, 1/24) IV
Ceftriaxone (0%, 0/21) IV
Oral Surgery Katoh 1992 62 Moderate Bacteremia Clindamycin ( 6%, 1/17) N/A No difference
600mg penicillin (16%, 8/50) No treatment Favors
Oral Surgery Martin 1964 127 Moderate Bacteremia 300mg penicillin (19%, 5/27) (54%, 27/50) Penicillin
Appleman Placebo (44%,
Periodontology 1982 31 Moderate Bacteremia Cephalexin (36%, 10/28) 11/25) No difference
Mysteclin plus dental
Gutverg prophylaxis (10%, 5/52) No Treatment Favors
Periodontology 1962 163 Moderate Bacteremia Mysteclin (5%, 3/57) (36%, 24/67) Mysteclin
Azithromycin (20%, 2/10)
Morozumi Essential Oil Antiseptic (70%, No Treatment Favors
Periodontology 2010 30 High Bacteremia 7/10) (90%, 9/10) Azithromycin
Brennan Placebo (20%, Favors
Restorative 2007 100 Moderate Bacteremia Amoxicillin (6%, 3/49) 10/51) Amoxicillin
260
Table 68 Topical Antimicrobial Prophylaxis Studies Excluded from Recommendation 2 Network Meta-Analysis
Outcome Active Treatment (%, n/N) or Control (%, n/N)
Procedure Study N Strength (specific type) (mean, SD) or (mean, SD) Results
No Treatment
Brushing Madsen 1974 29 Low Bacteremia Chlorhexidine (24%, 7/29) (34%, 10/29) No difference
Bacteremia
(Aerobic Placebo (35.1,
Chewing Fine 2010 22 Moderate CFU/ml) Essential Oil Rinse (8.0, 11.12) 36.29) Favors Rinse
Bacteremia
(Anaerobic Placebo (30.3,
Chewing Fine 2010 22 Moderate CFU/ml) Essential Oil Rinse (6.0, 7.92) 34.74) Favors Rinse
No Treatment (7%,
Dental Implant Pineiro 2010 50 Moderate Bacteremia Chlorhexidine (0%, 0/20) 2/30) No difference
Favors
Dental Povidone-
Prophylaxis Cherry 2007 60 Moderate Bacteremia Povidone-Iodine (10%, 3/30) Saline (30%, 9/30) Iodine
Bacteremia
Dental (Aerobic Placebo (38.72,
Prophylaxis Fine 1996 18 Moderate CFU/ml) Essential Oil Rinse (4.67, 2.14) 17.82) Favors Rinse
Bacteremia
Dental (Anaerobic Placebo (14.89,
Prophylaxis Fine 1997 18 Moderate CFU/ml) Essential Oil Rinse (1.61, 1.54) 7.86) Favors Rinse
Favors
Chlorhexidine (45%, 18/40) Povidone-
Injection Rahn 1995 120 Moderate Bacteremia Povidone-Iodine (28%, 11/40) Water (53%, 21/40) Iodine
Inter-dental No Treatment
Cleaning Madsen 1974 29 Low Bacteremia Chlorhexidine (24%, 7/29) (34%, 10/29) No difference
Fourrier Placebo (18%,
Intubation 2005 228 High Bacteremia Antiseptic Rinse (18%, 20/114) 21/114) No difference
Huffman Cetylpyridinium Chloride (83%,
Oral surgery 1974 25 Low Bacteremia 10/12) Saline (70%, 9/13) No difference
No Treatment (7%,
Orthodontistry Erverdi 2001 150 Low Bacteremia Chlorhexidine (3%, 2/80) 5/70) No difference
Favors
Brenman Placebo (58%, Povidone-
Periodontology 1974 52 Moderate Bacteremia Povidone-Iodine (23%, 6/26) 15/26) Iodine
261
Outcome Active Treatment (%, n/N) or Control (%, n/N)
Procedure Study N Strength (specific type) (mean, SD) or (mean, SD) Results
Chlorhexidine (20%, 2/10) No Treatment
Periodontology Lofthus 1991 30 Moderate Bacteremia Water (40%, 4/10) (30%, 3/10) No difference
Azithromycin (20%, 2/10)
Morozumi Essential Oil Antiseptic (70%, No Treatment Favors
Periodontology 2010 30 High Bacteremia 7/10) (90%, 9/10) Azithromycin
Chlorhexidine (27%, 4/15) No Treatment
Periodontology Waki 1990 54 Moderate Bacteremia Water (15%, 2/13) (13%, 2/15) No difference
No Treatment (9%,
Suture Brown 1998 55 Moderate Bacteremia Chlorhexidine (15%, 4/27) 2/22) No difference
262
APPENDIX XII
QUALITY AND APPLICABILITY TABLES FOR INCLUDED STUDIES
Table 69 APPRAISE Table of Prognostic Studies for Recommendation 1, Direct Evidence
●: Domain free of flaws
○: Domain flaws present
Investigator Bias
Prospective
Outcomes
Analysis
Analysis
Patients
Model
Power
Study Quality Applicability
Berbari 2010 ● ● ○ ● ● Moderate ● ○ ● Moderate
Table 70 APPRAISE Table of Treatment Studies for Recommendation 1, Dental Prophylaxis

Compliance and Adherence

Intervention and Expertise

Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Study Outcome Quality Applicability
Baltch 1982 Bacteremia ● ○ ○ ○ ● ● ○ Low ● ○ ● ● Moderate
263
Table 71 APPRAISE Table of Treatment Studies for Recommendation 1, Intubation


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Lockhart
2004
Bacteremia ● ● ● ● ● ● ● High ● ○ ● ● Moderate
264
Table 72 APPRAISE Table of Treatment Studies for Recommendation 1, Oral Surgery


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Goker 1992 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ● Moderate
Josefsson
1985
Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ● Moderate
Katoh 1992 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ● Moderate
Martin 1964 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ● Moderate
265
Table 73 APPRAISE Table of Treatment Studies for Recommendation 1, Periodontology


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Appleman
1981
Gutverg 1962 Bacteremia ● ○ ○ ○ ● ● ● Moderate ● ○ ● ● Moderate
Morozumi
2010
Bacteremia ● ● ○ ● ● ● ● High ● ○ ● ● Moderate
266
Table 74 APPRAISE Table of Treatment Studies for Recommendation 1, Restorative Procedure


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Brennan
2007
Table 75 APPRAISE Table of Treatment Studies for Recommendation 1, Extraction



Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Aitken 1995 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ○ Moderate
Cannell 1991 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ○ Moderate
267


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Casolari
1989
Bacteremia ● ○ ○ ○ ● ● ● Moderate ● ○ ○ ○ Moderate
Coulter 1990 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ○ Moderate

DeVries
1972
Bacteremia ● ○ ● ○ ○ ● ○ Low ● ○ ● ○ Moderate
Dios 2006 Bacteremia ● ○ ● ○ ● ● ● Moderate ● ○ ● ● Moderate
Hall 1993 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ○ Moderate
Hall 1996 Bacteremia ● ○ ● ○ ● ● ● Moderate ● ○ ● ○ Moderate
Hall 1996 Bacteremia ● ○ ● ○ ● ● ● Moderate ● ○ ● ○ Moderate
Head 1984 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ○ Moderate
Jokinen 1970 Bacteremia ● ○ ○ ○ ● ● ● Moderate ● ○ ○ ○ Moderate
Khairat 1966 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ○ Moderate
268


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Lockhart
2004
Bacteremia ● ● ● ● ● ● ● High ● ● ● ● Moderate
Lockhart
2008
Bacteremia ● ● ● ● ● ● ● High ● ● ● ● Moderate
Maskell 1986 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ○ Moderate
Roberts 1987 Bacteremia ● ○ ○ ● ● ● ○ Moderate ● ○ ○ ● Moderate

Shanson
1978
Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ○ Moderate
Shanson
1985
Shanson
1987
Vergis 2001 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ○ Moderate

Wahlmann
1999
Bacteremia ● ○ ○ ○ ● ● ○ Low ● ○ ○ ○ Moderate
269
Table 76 APPRAISE Table of Treatment Studies for Recommendation 2, Brushing


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Madsen
1974
Bacteremia ● ○ ○ ○ ● ● ○ low ● ○ ● ● Moderate
270
Table 77 APPRAISE Table of Treatment Studies for Recommendation 2, Chewing

Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Fine 2010 Bacteremia ● ○ ● ● ● ● ○ Moderate ● ○ ● ● Moderate
Table 78 APPRAISE Table of Treatment Studies for Recommendation 2, Dental Implant


○: Domain flaws present Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Pineiro
2010
Bacteremia ● ○ ○ ○ ● ● ● Moderate ● ○ ● ● Moderate
271
Table 79 APPRAISE Table of Treatment Studies for Recommendation 2, Dental Prophylaxis


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Cherry 2007 Bacteremia ● ○ ○ ○ ● ● ● Moderate ● ○ ● ● Moderate
Fine 1996 Bacteremia ● ● ● ○ ● ● ○ Moderate ● ○ ● ● Moderate
Table 80 APPRAISE Table of Treatment Studies for Recommendation 2, Injection



Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Rahn 1995 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ● Moderate
272
Table 81 APPRAISE Table of Treatment Studies for Recommendation 2, Inter-detal Cleaning


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Madsen
1974
Bacteremia ● ○ ○ ○ ● ● ○ low ● ○ ● ● Moderate
Table 82 APPRAISE Table of Treatment Studies for Recommendation 2, Intubation



Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Fourrier
2005
Bacteremia ● ● ● ● ● ● ● High ● ○ ● ● Moderate
273
Table 83 APPRAISE Table of Treatment Studies for Recommendation 2, Oral Surgery


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Huffman
1974
Bacteremia ● ○ ○ ○ ● ● ○ Low ● ○ ● ● Moderate
Table 84 APPRAISE Table of Treatment Studies for Recommendation 2, Orthodontistry



Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Erverdi 2001 Bacteremia ● ○ ○ ○ ● ● ○ Low ● ○ ● ● Moderate
274
Table 85 APPRAISE Table of Treatment Studies for Recommendation 2, Periodontology


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Brenman
1974
Lofthus
1991
Morozumi
2010
Bacteremia ● ● ○ ● ● ● ● High ● ○ ● ● Moderate
Waki 1990 Bacteremia ● ○ ● ○ ● ● ● Moderate ● ○ ● ● Moderate
275
Table 86 APPRAISE Table of Treatment Studies for Recommendation 2, Suture


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Brown 1998 Bacteremia ● ○ ● ○ ● ● ● Moderate ● ○ ● ● Moderate
Table 87 APPRAISE Table of Treatment Studies for Recommendation 2, Tooth Extraction



Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Casolari
1989
Cutcher
1971
276


Group Comparability
Treatment Integrity
Group Assignment
Investigator Bias
Measurement
Participants
Hypothesis
Blinding
Analysis
Francis
1973
Jokinen
1970
Jones 1970 Bacteremia ● ○ ○ ○ ● ● ○ Low ● ○ ● ● Moderate

Lockhart
1996
Bacteremia ● ● ● ● ● ● ○ High ● ○ ● ● Moderate
MacFarlane
1984
Nasif 1977 Bacteremia ● ○ ○ ○ ● ● ○ Low ● ○ ● ● Moderate
Rahn 1995 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ● Moderate
Scopp 1971 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ● Moderate
Sweet 1978 Bacteremia ● ○ ● ○ ● ● ○ Moderate ● ○ ● ● Moderate
Tomas 2007 Bacteremia ● ○ ○ ● ● ● ● Moderate ● ○ ● ● Moderate
277
Study
1992
Yamalik
Outcome
Bacteremia
Hypothesis
Group Assignment
Blinding
Group Comparability
Treatment Integrity
Measurement
278
● ○ ○ ○ ● ● ○
Investigator Bias
Low
Quality
Participants

● ○ ● ●
Analysis
Moderate
Applicability
Table 88 APPRAISE Table of Prognostic Studies for Recommendation 3, Brushing
Investigator Bias
Prospective
Outcomes
Analysis
Analysis
Patients
Model
Power
Ashare 2009 ● ● ○ ○ ● Low ● ○ ○ Moderate
Bhanji 2002 ● ● ○ ○ ● Low ● ○ ○ Moderate
Forner 2006 ● ● ○ ○ ● Low ● ○ ○ Moderate

Lockhart
2009 ● ● ○ ○ ● Low ● ○ ○ Moderate
Silver 1977 ● ● ○ ○ ● Low ● ○ ○ Moderate
279
Table 89 APPRAISE Table of Prognostic Studies for Recommendation 3, Chewing
Investigator Bias
Prospective
Outcomes
Analysis
Analysis
Patients
Model
Power
Forner 2006 ● ○ ○ ○ ● Very Low ● ○ ○ Moderate
280
Table 90 APPRAISE Table of Prognostic Studies for Recommendation 3, Dental Prophylaxis
Investigator Bias
Prospective
Outcomes
Analysis
Analysis
Patients
Model
Power
Cherry 2007 ● ○ ○ ● ● Low ● ○ ○ Moderate
De Leo 1974 ● ● ○ ○ ● Low ● ○ ○ Moderate
Forner 2006 ● ● ○ ○ ● Low ● ○ ○ Moderate
Trivedi 1984 ● ● ○ ○ ● Low ● ○ ○ Moderate
281
Table 91 APPRAISE Table of Prognostic Studies for Recommendation 3, Inter-dental Cleaning
Investigator Bias
Prospective
Outcomes
Analysis
Analysis
Patients
Model
Power
Crasta 2009 ● ● ○ ○ ● Low ● ○ ○ Moderate
Lineberger
1973 ● ● ○ ○ ● Low ● ○ ○ Moderate
282
Table 92 APPRAISE Table of Prognostic Studies for Recommendation 3, Intubation
Investigator Bias
Prospective
Outcomes
Analysis
Analysis
Patients
Model
Power
Valdes 2008 ● ● ○ ○ ● Low ● ○ ○ Moderate
283
Table 93 APPRAISE Table of Prognostic Studies for Recommendation 3, Oral Surgery
Investigator Bias
Prospective
Outcomes
Analysis
Analysis
Patients
Model
Power
Enabulele
2008 ● ● ○ ○ ● Low ● ○ ○ Moderate
Roberts 1998 ● ● ○ ○ ● Low ● ○ ○ Moderate
Takai 2005 ● ● ○ ○ ● Low ● ○ ○ Moderate
Tomas 2008 ● ● ○ ○ ● Low ● ○ ○ Moderate
284
Table 94 APPRAISE Table of Prognostic Studies for Recommendation 3, Periodontology
Investigator Bias
Prospective
Outcomes
Analysis
Analysis
Patients
Model
Power
Daly 1997 ● ○ ○ ○ ● Low ● ○ ○ Moderate
Daly 2001 ● ● ○ ○ ● Low ● ○ ○ Moderate
285
Table 95 APPRAISE Table of Prognostic Studies for Recommendation 3, Restorative Procedure
Investigator Bias
Prospective
Outcomes
Analysis
Analysis
Patients
Model
Power
Brennan
2007 ● ● ○ ○ ○ Very Low ● ○ ○ Moderate
286
Table 96 APPRAISE Table of Prognostic Studies for Recommendation 3, Tooth Extraction
Investigator Bias
Prospective
Outcomes
Analysis
Analysis
Patients
Model
Power
Barbosa
2010 ● ● ○ ○ ● Moderate ● ○ ○ Moderate
Coulter 1990 ● ● ○ ○ ● Moderate ● ○ ○ Moderate

Enabulele
Lockhart
Lockhart
Okabe 1995 ● ● ○ ○ ● Moderate ● ○ ○ Moderate
Roberts 1998 ● ● ○ ○ ● Moderate ● ○ ○ Moderate

Wahlmann
287
Table 97 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Brushing
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Bhanji 2002 Bacteremia I ● ● ● ● High ● ○ ○ Moderate
Forner 2006 Bacteremia I ● ● ● ● High ● ○ ○ Moderate
Lockhart
2008
Bacteremia I ● ● ● ● High ● ○ ○ Moderate
Lucas 2000 Bacteremia P ● ● ● ○ Moderate ● ○ ○ Moderate
Sconyers
1979
Sconyers
1973
Silver 1979 Bacteremia P ● ● ● ● High ● ○ ○ Moderate
288
Table 98 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Brushing
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Degling
1972
Bacteremia P ● ● ● ● High ● ○ ○ Moderate

Murphy
2006
Trivedi
1984
Bacteremia P ● ● ● ○ Moderate ● ○ ○ Moderate
289
Table 99 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Cleft Palate
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Marzoni
1983
Bacteremia P ● ● ○ ○ Low ● ○ ○ Moderate
Table 100 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Dental Implant
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Pineiro
2010
290
Table 101 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Dental Prophylaxis
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Cherry
2007
De Leo
1974

Heimdahl
1990
Lucas 1999 Bacteremia P ● ● ● ○ Moderate ● ○ ○ Moderate

Trivedi
1984
Winslow
1960
291
Table 102 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Endodontic
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Baumgartner
1977
Baumgartner
1976
Bender 1963 Bacteremia I ● ● ● ● High ● ○ ○ Moderate

Debelian
1995
Heimdahl
1990
Savarrio
2005
292
Table 103 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Injections
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Roberts
1998
Rahn 1995 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
293
Table 104 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Inter-dental Cleaning
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Berger 1974 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
Crasta 2009 Bacteremia I ● ● ● ● High ● ○ ○ Moderate
Felix 1971 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate

Lineberger
1973
Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
Ramadan 1975 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
Romans 1971 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate

The American
Academy of
Periodontology
1972
Wank 1976 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
294
Table 105 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Intubation
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Ali 1992 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
Berry 1973 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
Dinner 1987 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate

Hansen
1989
Oncag 2005 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate

Roberts
1997
Valdes 2008 Bacteremia I ● ● ● ● High ● ○ ○ Moderate
295
Table 106 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Oral Surgery
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Enabulele
2008
Flood 1990 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate

Heimdahl
1990
Josefsson
1985
Martin 1964 Bacteremia P ● ● ● ○ Moderate ○ ○ ○ Low

Rajasuo
2004
Bacteremia P ● ○ ● ● Moderate ● ○ ○ Moderate
Rajasuo
2004
Roberts
1997
Roberts
1998
Bacteremia P ● ○ ● ○ Low ● ○ ○ Moderate
Takai 2005 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
Tomas 2008 Bacteremia P ● ○ ● ○ Low ● ○ ○ Moderate
296
Table 107 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Orthodontic
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Burden
2004
Degling
1972
Erverdi
1999
Gürel 2009 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
297
Table 108 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Periodontology
Investigator Bias
Measurement
/Prevalence
Participants
Participants
Incidence
Outcomes
Outcome
Analysis
Casolari
1989
Conner 1967 Bacteremia P ● ● ● ● High ● ○ ○ Moderate
Daly 1997 Bacteremia I ● ● ● ● High ● ○ ○ Moderate
Daly 2001 Bacteremia I ● ● ○ ● Moderate ● ○ ○ Moderate

Gutverg
1962
Kinane 2005 Bacteremia P ● ○ ● ○ Moderate ○ ○ ○ Low

Lafaurie
2007
Bacteremia I ● ● ● ○ High ○ ○ ○ Moderate
Lineberger
1973
Bacteremia I ● ● ○ ○ Moderate ○ ○ ○ Moderate
Lofthus
1991
Lucartorto
1992
298
Investigator Bias
Measurement
/Prevalence
Participants
Participants
Incidence
Outcomes
Outcome
Analysis
Morozumi
2010
Rogosa 1960 Bacteremia I ● ● ○ ○ Moderate ○ ○ ○ Moderate
Wada 1968 Bacteremia I ● ● ○ ○ Moderate ○ ○ ○ Moderate
Waki 1990 Bacteremia I ● ● ● ○ High ○ ○ ○ Moderate
299
Table 109 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Restorative Procedure
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Oncag 2006 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
Roberts
2000
Bacteremia P ● ● ● ○ Moderate ● ○ ● Moderate
Sonbol 2009 Bacteremia P ● ● ● ○ Moderate ● ○ ○ Moderate
300
Table 110 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Sialography
Investigator Bias
Measurement
/Prevalence
Participants
Participants
Incidence
Outcomes
Outcome
Analysis
Lamey 1985 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
Nixon 2009 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
301
Table 111 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Suture
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Brown 1998 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
Giglio 1992 Bacteremia P ● ● ● ○ Moderate ● ○ ○ Moderate
King 1988 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate

Wampole
1978
302
Table 112 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Teething
Investigator Bias
Measurement
Participants
Participants
/Prevalence
Outcomes
Incidence
Outcome
Analysis
Soliman
1977
303
Table 113 APPRAISE Table of Incidence/Prevalence Studies for Control/Baseline, Tooth Extraction
Investigator Bias
Measurement
/Prevalence
Participants
Participants
Incidence
Outcomes
Outcome
Analysis
Barbosa
2010

Casolari
1989
Coulter 1990 Bacteremia P ● ● ● ● High ● ○ ○ Moderate

Crawford
1974
DeVries
1972
Francis 1973 Bacteremia P ● ● ● ○ Moderate ● ○ ○ Moderate

Heimdahl
1990
Khairat 1966 Bacteremia I ● ● ● ○ Moderate ● ○ ○ Moderate
Maskell 1896 Bacteremia P ● ● ● ○ Moderate ● ○ ○ Moderate
304
Investigator Bias
Measurement
/Prevalence
Participants
Participants
Incidence
Outcomes
Outcome
Analysis
Peterson
1976
Roberts 1992 Bacteremia P ● ● ● ○ Moderate ● ○ ○ Moderate

Shanson
1978
Shanson
1987
Tomas 2007 Bacteremia P ● ○ ● ● Moderate ● ○ ○ Moderate
Tomas 2007 Bacteremia P ● ○ ● ● Moderate ● ○ ○ Moderate
Trivedi 1984 Bacteremia P ● ● ● ○ Moderate ● ○ ○ Moderate
305
APPENDIX XIII
CONFLICT OF INTEREST
All members of the AAOS work group disclosed any conflicts of interest prior to the
development of the recommendations for this guideline. Conflicts of interest are
disclosed with the American Academy of Orthopaedic Surgeons via a private on-line
reporting database and also verbally at the recommendation approval meeting.
Disclosure Items: (n) = Respondent answered 'No' to all items indicating no conflicts.
1= Royalties from a company or supplier; 2= Speakers bureau/paid presentations for a
company or supplier; 3A= Paid employee for a company or supplier; 3B= Paid consultant
for a company or supplier; 3C= Unpaid consultant for a company or supplier; 4= Stock or
stock options in a company or supplier; 5= Research support from a company or supplier
as a PI; 6= Other financial or material support from a company or supplier; 7= Royalties,
financial or material support from publishers; 8= Medical/Orthopaedic publications
editorial/governing board; 9= Board member/committee appointments for a society.
William C. Watters, III, MD, Work Group Co-Chair: 1 (Stryker); 3B (Palladian;

Stryker); 4 (Intrinsic Orthopedics); 8 (Official Disability Guidelines; Spine; The Spine
Journal); 9 (American Board of Spine Surgery; North American Spine Society);
Submitted on: 08/11/2011.
Michael P. Rethman, DDS, MS, Work Group Co-Chair: 3B (Colgate-Palmolive); 4

(Colgate-Palmolive; Pfizer); 9 (American Dental Association Foundation); Submitted on:
02/05/2013.
Elliott Abt, DDS: (n) Submitted on: 10/19/2011.
Harry C. Futrell, DMD: (n) Submitted on: 10/04/2011.
Stephen O. Glenn, DDS: 8 (Key/ Alliance of the American Dental Association); 9

(American Dental Association); Submitted on: 10/19/2011.
John Hellstein, DDS, MS: 9 (American Academy of Oral and Maxillofacial Pathology;
American Board of Oral and Maxillofacial Pathology; American Dental Association
Council on Scientific Affairs; Basal Cell Carcinoma Nevus Syndrome Life Support
Network); Submitted on: 10/04/2011.
Mark J. Steinberg, DDS, MD: 9 (American Association of Oral and Maxillofacial

Surgeons); Submitted on: 04/19/2011.
Richard Parker Evans, MD: 2 (Johnson & Johnson; Smith & Nephew)
Michael J. Goldberg, MD: 8 (Journal Children's Orthopaedics; Journal of Pediatric

Orthopedics); 9 (AAOS); Submitted on: 04/27/2011.
Calin Stefan Moucha, MD: 2 (3M) 4 (Auxillium); 9 (AAOS); Submitted on:

10/02/2011.
306
Richard J. O’Donnell, MD: 9 (National Comprehensive Cancer Network; Northern
California Chapter, Western Orthopaedic Association; Orthopaedic Surgical
Osseointegration Society; Sarcoma Alliance); Submitted on: 10/04/2011.
Paul A. Anderson, MD: 1 (Pioneer; Stryker); 3B (Aesculap/B.Braun); 3C (Expanding

Orthopedics; SI Bone; Spatatec; Titan Surgical); 4 (Pioneer Surgical; SI Bone; Spartec;
Titan Surgical); 8 (Clinical Orthopaedics and Related Research; Journal of Bone and
Joint Surgery - American; Journal of Orthopaedics and Traumatology; Journal of Spinal
Disorders; Neurosurgery; Spine; Spine Arthropalsty Journal); 9 (American Academy of
Orthopaedic Surgeons, American Society for Testing and Materials; North American
Spine Society; Spine Arthroplasty Society; Spine Section of American Association of
Neurological Surgeons/Congress of Neurological Surgeons); Submitted on: 04/07/2011.
John E. O’Toole, MD: 1 (Globus Medical); 3B (Globus Medical; Pioneer Surgical); 3C

(Medtronic); Submitted on: 10/19/2011.
David J. Kolessar, MD: 4 (Zimmer); Submitted on: 04/07/2011.
Karen C. Carroll, MD, FCAP: 7 (ASM Press; McGraw-Hill); 8 (Infectious Diseases in

Clinical Practice; Journal Clinical Microbiology/ASM Press); Submitted on: 10/05/2011.
Kevin Garvin, MD: 1 (Biomet); 8 (Wolters Kluwer Health - Lippincott Williams &
Wilkins); 9 (AAOS; AAOS; American Orthopaedic Association; American Orthopaedic
Association); Submitted on: 09/21/2011.
Douglas R. Osmon, MD: 9 (Musculoskeletal infection society); Submitted on:

10/05/2011.
Anthony Rinella, MD: (n); Submitted on: 10/05/2011.
Angela Hewlett, MD, MS: 9 (Society for Healthcare Epidemiology of America);

Submitted on: 10/04/2011.
William Robert Martin, III, MD: 9 (National Board of Medical Examiners); Submitted
on: 03/12/2010.
Deborah S. Cummins, PhD: (n); Submitted on 11/15/2012.
Sharon Song, PhD: (n); Submitted on 1/28/2013.
Patrick Sluka, MPH: (n); Submitted on 10/19/2011.
Kevin Boyer, MPH: (n); Submitted on 03/05/2012.
Anne Woznica, MLIS: (n); Submitted on 10/03/2012.
Helen Ristic, PhD: (n); Submitted on 01/15/2013.
Nicholas Buck Hanson, MPH: (n); Submitted on 01/14/2013.
307
REFERENCES
(1) Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision
hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint
Surg Am 2007;89(4):780-785.
(2) Della Valle CJ, Zuckerman JD, Di Cesare PE. Periprosthetic Sepsis. Clin Orthop
2004;(420):26-31.
(3) Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go

gently into that good night. JAMA 2009;301(8):868-869.
(4) Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington,

D.C.: National Academies Press; 2011.
(5) Institute of Medicine. Conflict of Interest in Medical Research, Education, and

Practice. Washington, D.C.: National Academies Press; 2009.
(6) Hirsh J, Guyatt G. Clinical experts or methodologists to write clinical guidelines?

Lancet 2009;374(9686):273-275.
(7) Atkins D, Eccles M, Flottorp S et al. Systems for grading the quality of evidence
and the strength of recommendations I: critical appraisal of existing approaches
The GRADE Working Group. BMC Health Serv Res 2004;4(1):38.
(8) Poolman RW, Struijs PA, Krips R, Sierevelt IN, Lutz KH, Bhandari M. Does a
"Level I Evidence" rating imply high quality of reporting in orthopaedic
randomised controlled trials? BMC Med Res Methodol 2006;6:44.
(9) GRADE handbook for grading quality of evidence and strength of

recommendation. The GRADE Working Group; 2009.
(10) Moher D, Dulberg CS, Wells GA. Statistical power, sample size, and their
reporting in randomized controlled trials. JAMA 1994;272(2):122-124.
(11) Institute of Medicine. Finding What Works in Health Care: Standards for
Systematic Reviews. Washington, D.C.: National Academies Press; 2011.
(12) Morrison A, Moulton K, Clark M et al. English-Language Restriction When

Conducting Systematic Review-based Meta-analyses: Systemataic Review of
Published Studies. Ottawa: Canadian Agency for Drugs and Technologies in
Health; 2009.
(13) Kastner M, Wilczynski NL, Walker-Dilks C, McKibbon KA, Haynes B. Age-

specific search strategies for Medline. J Med Internet Res 2006;8(4):e25.
308
(14) Haynes RB, McKibbon KA, Wilczynski NL, Walter SD, Werre SR. Optimal
search strategies for retrieving scientifically strong studies of treatment from
Medline: analytical survey. BMJ 2005;330(7501):1179.
(15) Montori VM, Wilczynski NL, Morgan D, Haynes RB. Optimal search strategies
for retrieving systematic reviews from Medline: analytical survey. BMJ
2005;330(7482):68.
(16) Wong SS, Wilczynski NL, Haynes RB. Comparison of top-performing search
strategies for detecting clinically sound treatment studies and systematic reviews
in MEDLINE and EMBASE. J Med Libr Assoc 2006;94(4):451-455.
(17) Kastner M, Wilczynski NL, Walker-Dilks C, McKibbon KA, Haynes B. Age-

specific search strategies for Medline. J Med Internet Res 2006;8(4):e25.
(18) Wong SS, Wilczynski NL, Haynes RB. Optimal CINAHL search strategies for
identifying therapy studies and review articles. J Nurs Scholarsh 2006;38(2):194-
199.
(19) Treadwell JR, Tregear SJ, Reston JT, Turkelson CM. A system for rating the
stability and strength of medical evidence. BMC Med Res Methodol 2006;6:52.
(20) Higgins J, Altman D. Assessing risk of bias in included studies. In: Higgins J,
Green S, editors. Cochrane Handbook for SYstematic Reviews of Interventions.
John Wiley & Sons; 2008. 187-241.
(21) Thorpe KE, Zwarenstein M, Oxman AD et al. A pragmatic-explanatory

continuum indicator summary (PRECIS): a tool to help trial designers. J Clin
Epidemiol 2009;62(5):464-475.
(22) Sismondo S. Pharmaceutical company funding and its consequences: a qualitative

systematic review. Contemp Clin Trials 2008;29(2):109-113.
(23) Ezzet KA. The prevalence of corporate funding in adult lower extremity research
and its correlation with reported results. J Arthroplasty 2003;18(7 Suppl 1):138-
145.
(24) Khan SN, Mermer MJ, Myers E, Sandhu HS. The roles of funding source, clinical
trial outcome, and quality of reporting in orthopedic surgery literature. Am J
Orthop (Belle Mead NJ) 2008;37(12):E205-E212.
(25) Montori VM, Jaeschke R, Schunemann HJ et al. Users' guide to detecting

misleading claims in clinical research reports. BMJ 2004;329(7474):1093-1096.
(26) Salanti G, Higgins JP, Ades AE, Ioannidis JP. Evaluation of networks of
randomized trials. Stat Methods Med Res 2008;17(3):279-301.
309
(27) Petitti DB, Teutsch SM, Barton MB, Sawaya GF, Ockene JK, DeWitt T. Update
on the methods of the U.S. Preventive Services Task Force: insufficient evidence.
Ann Intern Med 2009;150(3):199-205.
(28) Murphy MK, Black LA, Lamping DL, McKee CM, Sanderson C.F., Askam J.
Consensus development methods, and their use in clinical guideline development.
Health Technol Assess 1998.
(29) Fleming TR, DeMets DL. Surrogate end points in clinical trials: are we being
misled? Ann Intern Med 1996;125(7):605-613.
(30) Shaughnessy AF, Slawson DC. What happened to the valid POEMs? A survey of
review articles on the treatment of type 2 diabetes. BMJ 2003;327(7409):266.
(31) Grimes DA, Schulz KF. Surrogate end points in clinical research: hazardous to
your health. Obstet Gynecol 2005;105(5 Pt 1):1114-1118.
(32) Prentice RL. Surrogate endpoints in clinical trials: definition and operational
criteria. Stat Med 1989;8(4):431-440.
(33) Stata Statistical Software: Release 10 [computer program]. College Station, TX:
StatCorp LP; 2007.
(34) Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the
median, range, and the size of a sample. BMC Med Res Methodol 2005;5(1):13.
(35) Lu G, Ades AE. Combination of direct and indirect evidence in mixed treatment
comparisons. Stat Med 2004;23(20):3105-3124.
(36) Brooks S, Gelman A. Alternative methods for monitoring convergence of iterative

simulations. Journal of Computational and Graphical Statistics 1998;7:434-455.
(37) Dias S, Welton NJ, Caldwell DM, Ades AE. Checking consistency in mixed
treatment comparison meta-analysis. Stat Med 2010;29(7-8):932-944.
(38) DerSimonian R., Laird N. Meta-Analysis in Clinical Trials. Controlled Clinical

Trials 1986;7:177-188.
(39) Berbari 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 2010;50(1):8-16.
310

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Prevention of Orthopaedic Implant

Infection in Patients Undergoing Dental

Evidence-Based Clinical Practice Guideline

Published 2012 by the American Academy of Orthopaedic Surgeons

AAOS Clinical Practice Guideline Unit ii v0.2 2.2.2012

This summary of recommendations is not intended to stand alone. Treatment decisions

1. The practitioner might consider discontinuing the practice of routinely prescribing

Grade of Recommendation: Limited

Implications: Practitioners should be cautious in deciding whether to follow a recommendation

Grade of Recommendation: Inconclusive

Implications: Practitioners should feel little constraint in deciding whether to follow a

AAOS Clinical Practice Guideline Unit iii v0.2 2.2.2012

Grade of Recommendation: Consensus

Implications: Practitioners should be flexible in deciding whether to follow a recommendation

AAOS Clinical Practice Guideline Unit iv v0.2 2.2.2012

Indirect evidence – Evidence that demonstrates a relationship between a dental

Prevalence – Existing cases of a disease in a population during a specified time period

Case-control study – Comparison of a diseased group (cases) to a group without disease

Surrogate Outcome – An outcome (such as a laboratory measurement) that is used as a

AAOS Clinical Practice Guideline Unit v v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit vi v0.2 2.2.2012

Scoliosis Research Society Kevin Boyer, MPH

Additional collaborating organizations involved in this guideline development:

AAOS Clinical Practice Guideline Unit vii v0.2 2.2.2012

The Academy of General Dentistry

AAOS Clinical Practice Guideline Unit viii v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit ix v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit x v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit xi v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit xii v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit xiii v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit xiv v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit xv v0.2 2.2.2012

GOALS AND RATIONALE

AAOS Clinical Practice Guideline Unit 1 v0.2 2.2.2012

BURDEN OF DISEASE AND ETIOLOGY

POTENTIAL HARMS, BENEFITS, AND CONTRAINDICATIONS

AAOS Clinical Practice Guideline Unit 2 v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit 3 v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit 4 v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit 5 v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit 6 v0.2 2.2.2012

Establishing transparency Yes

Management of Conflict of Interest Yes

No – AAOS does not involve

Articulation of recommendations Yes

External review Yes

AAOS Clinical Practice Guideline Unit 7 v0.2 2.2.2012

AAOS Clinical Practice Guideline Unit 8 v0.2 2.2.2012

FORMULATING PRELIMINARY RECOMMENDATIONS

FULL DISCLOSURE INFORMATION

STUDY SELECTION CRITERIA

 Study must be of patient population of interest (as described by preliminary

AAOS Clinical Practice Guideline Unit 9 v0.2 2.2.2012

We did not include systematic reviews or meta-analyses conducted by others, or guidelines

We supplemented searches of electronic databases with manual screening of the bibliographies

BEST EVIDENCE SYNTHESIS

AAOS Clinical Practice Guideline Unit 10 v0.2 2.2.2012

APPRAISING EVIDENCE QUALITY AND APPLICABILITY

AAOS Clinical Practice Guideline Unit 11 v0.2 2.2.2012