**Is Antibiotic Prophylaxis Necessary before Dental Implant Procedures in Patients with Orthopaedic Prostheses? A Systematic Review**

**Angel-Orión Salgado-Peralvo 1,2 , Juan-Francisco Peña-Cardelles 2,3,4,\* , Naresh Kewalramani 2,5 , Alvaro Garcia-Sanchez <sup>6</sup> , María-Victoria Mateos-Moreno <sup>7</sup> , Eugenio Velasco-Ortega 1,2 , Iván Ortiz-García 1,2 , Álvaro Jiménez-Guerra 1,2, Dániel Végh 8,9 , Ignacio Pedrinaci 10,11 and Loreto Monsalve-Guil 1,2**


**Abstract:** As the population ages, more and more patients with orthopaedic prostheses (OPs) require dental implant treatment. Surveys of dentists and orthopaedic surgeons show that prophylactic antibiotics (PAs) are routinely prescribed with a very high frequency in patients with OPs who are about to undergo dental procedures. The present study aims to determine the need to prescribe prophylactic antibiotic therapy in patients with OPs treated with dental implants to promote their responsible use and reduce the risk of antimicrobial resistance. An electronic search of the MEDLINE database (via PubMed), Web of Science, LILACS, Google Scholar, and OpenGrey was carried out. The criteria used were those described by the PRISMA® Statement. No study investigated the need to prescribe PAs in patients with OPs, so four studies were included on the risk of infections of OPs after dental treatments with varying degrees of invasiveness. There is no evidence to suggest a relationship between dental implant surgeries and an increased risk of OP infection; therefore, PAs in these patients are not justified. However, the recommended doses of PAs in dental implant procedures in healthy patients are the same as those recommended to avoid infections of OPs.

**Keywords:** antibiotic prophylaxis; antibiotics; joint replacement; prosthetic joint infection; oral implantology; dental implants

#### **1. Introduction**

Today, life expectancy is higher than ever before due to the declining mortality rate of young people in developing countries [1], while "developed" countries are experiencing

**Citation:** Salgado-Peralvo, A.-O.; Peña-Cardelles, J.-F.; Kewalramani, N.; Garcia-Sanchez, A.; Mateos-Moreno, M.-V.; Velasco-Ortega, E.; Ortiz-García, I.; Jiménez-Guerra, Á.; Végh, D.; Pedrinaci, I.; et al. Is Antibiotic Prophylaxis Necessary before Dental Implant Procedures in Patients with Orthopaedic Prostheses? A Systematic Review. *Antibiotics* **2022**, *11*, 93. https:// doi.org/10.3390/antibiotics11010093

Academic Editor: Marc Maresca

Received: 8 December 2021 Accepted: 10 January 2022 Published: 12 January 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

a large decline in mortality at older ages, with an average life expectancy of 91 years for women and 86 years for men [2]. This increases the number of people in need of orthopaedic prostheses (OPs) of any kind [3]. In 2006, around 800,000 joint replacements (hip and knee, as well as elbow, wrist, ankle, metacarpophalangeal, and interphalangeal joints) were placed in the USA [4] and it is estimated that by 2030 these numbers will increase to 4 million for hip and knee replacements alone [5]. Globally, the age group with the highest prevalence of tooth loss is 79-year-olds. Future figures may be even higher, as between 1990 and 2015, there was a 40% increase in the number of people with oral conditions such as untreated caries and/or tooth loss [6]. For these reasons, it is expected that more and more professionals will be faced with patients with OPs requiring the replacement of missing teeth with dental implants.

Infection of orthopaedic prostheses (OPIs) occurs in 0.3 to 2% of patients with OPs [7], requiring additional orthopaedic surgery, as well as the use of antibiotics for a long period [5]. Depending on the timing of their occurrence concerning orthopaedic surgery, OPIs are classified as "early", "delayed", or "late". The first two occur before three months, and between 3 and 24 months post-surgery, respectively, and are related to orthopaedic surgery. On the other hand, late OPIs often result from the late growth of bacteria accidentally inoculated during bleeding procedures or from a distant septic focus [8,9] ("hematogenous orthopaedic prosthetic infections" (HOPIs)). It is estimated that around 10% of these infections are caused by bacteria present in the oral cavity [3]. However, the frequency, duration, and intensity of bacteraemia will influence the cumulative risk [8]. In this regard, classic animal model studies have shown that high bacterial counts (>1000 colony-forming units (CFU)/mL) are required for HOPIs to occur, which is often a consequence of systemic sepsis [10,11].

Various surveys have shown that 63.4% [12] to 71.5% [13] of orthopaedic surgeons consider the prescription of prophylactic antibiotics (PAs) to be necessary indefinitely in patients with hip prostheses who are going to undergo dental treatment. A survey conducted in Canada in 2014 revealed that around 70.7% of dentists routinely prescribe Pas and 21.7% consider it essential for the rest of the patient's life [12]. Despite that, currently, antibiotic prophylaxis for patients with prosthetic joints who are undergoing dental treatment is not routinely recommended in several countries, such as Australia [14], the United Kingdom [15], Canada [16], and New Zealand [17]. Namely, a recent survey of professionals dedicated to oral implantology studied for the first time their prescription habits for PAs in patients with hip prostheses, showing that 74.3% prescribe them, as they consider these patients to be at risk [18].

Considering the current context, these data should be considered where antimicrobial resistance causes around 33,000 deaths each year in the European Union [19]. The associated healthcare costs and lost productivity are estimated to be 1.5 billion euros per year [20]. It is a naturally occurring phenomenon, and this process is being accelerated by the inappropriate and indiscriminate use of antibiotics in humans, food-producing animals, and the environment. Immediate changes in the way antibiotics are prescribed and used are urgently needed. Even if new methods are developed, resistance will continue to pose a severe threat if current prescribing patterns are not modified [21]. In this sense, a recent meta-analysis revealed that the average prescribed dose of PAs in implant surgery is approximately 5 times higher than the one recommended to healthy patients without anatomical constraints [22]. Furthermore, there is only clear scientific proof on the recommended PA dose in the clinical situation mentioned above [23] and in bone augmentation with the implant placement done in one or two phases [21], that is, 2–3 g of amoxicillin an hour before the intervention [21,23], while in allergic patients, 500 mg of azithromycin, 1 h before surgery, has recently been suggested. [24]. Regarding the remaining clinical situations, the type of antibiotic prescribed and its posology is up to the professional, who in many cases tends to over-prescribe them.

Therefore, given the data described above, it is considered necessary to carry out a literature review to determine the need for PAs in patients with OPs who are going to be treated with dental implants to promote their responsible use.

#### **2. Materials and Methods**

The criteria used are the ones described in the PRISMA® (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Declaration [25].

#### *2.1. Focused Question*

The main objective was to answer the following "PICO" (P = patient/problem/population; I = intervention; C = comparison; O = outcome) question (Table 1).


**Table 1.** Breakdown of the "PICO" question.

<sup>1</sup> OPs, orthopaedic prostheses; <sup>2</sup> PAs, prophylactic antibiotics; <sup>3</sup> OPIs, orthopaedic prostheses infection.

In patients with OPs who are about to undergo an implant procedure, does the prescription of PAs decrease the risk of infection of OPs versus not taking them?

#### *2.2. Eligibility Criteria*

Before proceeding, inclusion and exclusion criteria were defined and applied to the resulting articles.

#### 2.2.1. Inclusion Criteria

The included studies comprised (a) human studies; (b) articles published in English or Spanish (c); meta-analysis; (d) systematic reviews; (e) randomized clinical trials (RCTs); (f) clinical trials; (g) clinical studies; (h) comparative studies; (i) multicentre studies; (j) observational studies; and (k) grey literature.

#### 2.2.2. Exclusion Criteria

The exclusion criteria determined the exclusion of the following: (a) experimental laboratory studies; (b) animal studies; (c) studies whose main topic was not the prescription of PAs before the dental procedure in patients with joint replacements; (d) duplicated articles; (e) books or chapters of books; (f) letters to the Editor; (g) commentaries; (h) literature reviews; and (i) surveys.

#### *2.3. Information Sources and Search Strategy*

A comprehensive search of the literature was conducted in the following databases: MEDLINE (via PubMed), Web of Science, Google Scholar, and LILACS. A search for unpublished studies (grey literature) was conducted on the OpenGrey database. Moreover, we examined the bibliographic references of the selected articles for publications that did not appear in the initial search and might be of interest.

The search was performed by two independent researchers (A.-O.S.-P. and J.-F.P.-C.). The search was temporarily restricted from 2 February 2011 to 2 February 2021, and was later updated on 16 February 2021.

MeSH (Medical Subject Headings) terms, keywords and other free terms were used with Boolean operators (OR, AND) to combine searches: (hip prosthesis OR hip replacement OR prosthesis joint OR joint replacement OR knee prosthesis OR knee replacement OR ankle prosthesis OR ankle replacement OR shoulder prosthesis OR shoulder replacement OR elbow prosthesis OR elbow replacement) AND (dental implant OR dental implants OR dental implantology OR oral implantology OR oral surgery OR dental OR dental treatment) AND (antibiotics OR preventive antibiotics OR antibiotic prophylaxis OR clindamycin OR amoxicillin OR erythromycin OR azithromycin OR metronidazole). The same keywords were used for all search platforms following the syntax rules for each database.

#### *2.4. Study Records*

Two researchers (A.-O.S.-P. and J.-F.P.-C.) independently compared the results to ensure completeness and removed duplicates. Then, the full title and abstracts of the remaining papers were screened individually. Finally, full-text articles included in this systematic review were selected according to the criteria described above. Disagreements over eligible studies to be included were discussed with a third reviewer (N.K.), and a consensus was reached. The reference list of the included studies was also reviewed for possible inclusion.

#### *2.5. Risk of Bias*

Data collection was conducted using a predetermined table to assess the resulting articles. Two independent reviewers (J.-F.P.-C. and A.G.-S.) evaluated the methodological quality of eligible studies following the Joanna Briggs Institute Checklist for Systematic Reviews and Research Syntheses [26], which incorporates 11 domains. The studies were classified as low-quality assessment studies (0–6) or as high-quality assessment studies (7–11).

#### **3. Results**

#### *3.1. Study Selection*

The search strategy resulted in 106 results, of which 99 remained after removing the duplicates. Then, two independent researchers (A.-O.S.-P. and J.-F.P.-C.) reviewed all the titles and abstracts and excluded 86 that were outside the scope of this review. Thus, we obtained 13 potential references. After reading the full text of those 13 papers, it was found that none answered the PICO question as they did not investigate the need to prescribe PAs in implant treatments to reduce the risk of OPIs. Six articles were included that investigated the risk of bacteraemia secondary to dental procedures with varying degrees of invasiveness, so extrapolations were made to establish clear guidelines on the need to administer PAs in implant procedures in these patients. The same situation occurred after the search in Google Scholar and the analysis of the references of the selected articles. Three articles were included in this way so that a total of four papers were analysed [5,7,27,28] (Figure 1).

#### *3.2. Study Characteristics*

Most of these studies focused on the appropriateness of the prescription of PAs in hip and/or knee prostheses [5,27] and joints in general. The main findings were described as follows.

The American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) have collaborated on the development of Clinical Practice Guidelines (CPGs) in patients with OPs. The first collaboration was in 2013 [5], where it was determined that it was not necessary to routinely prescribe PAs for dental procedures in patients with hip or knee replacements because, although PAs have been shown to reduce bacteria associ-

ated with dental procedures, no evidence links these bacteraemias to HOPIs. Nevertheless, the authors expressed that this decision should be left to the discretion of the professional and the patient after weighing the benefits/risks. This workgroup concluded that PAs would be "rare" or "perhaps appropriate" for non-invasive treatments, meaning those that do not require gingival/mucosa manipulation/perforation, as well as for invasive treatments in healthy patients. Among severely immunocompromised patients, patients with non-controlled diabetes (with levels of glycosylated haemoglobin (HbA1c) ≥ 8 or blood glucose level ≥ 200 mg/dL) and/or patients with a history of OPI, the prescription of PAs would be considered "appropriate". Patients with severely immunosuppressed states can be classified into the following groups, according to the Center for Disease Control and Prevention (CDC) guidelines [29]: (1) patients with stage III HIV/AIDS, i.e., patients with a CD4 T-lymphocyte count < 200 or opportunistic infections; (2) patients on chemotherapy with fever (absolute neutrophil count (ANC) < 2000) (39 ◦C) or severe neutropenia (ANC < 500) with or without fever; (3) patients with rheumatoid arthritis (RA) on treatment with disease-modifying biologic agents, including tumour necrosis factor-alpha (TNF-α) or prednisone > 10 mg/day (4) patients who have received a solid organ transplant and are on immunosuppressants; (5) patients with hereditary immunosuppressive diseases; and (6) patients with a bone marrow transplant from the pre-transplant period until the end of immunosuppressive treatment (usually about 36 months after surgery). *Antibiotics* **2022**, *11*, x FOR PEER REVIEW 5 of 12

**Figure 1.** PRISMA® flow diagram of the search processes and results. 1 PAs, prophylactic antibiotics; 2 OPIs, orthopaedic prostheses infection. **Figure 1.** PRISMA® flow diagram of the search processes and results. <sup>1</sup> PAs, prophylactic antibiotics; <sup>2</sup> OPIs, orthopaedic prostheses infection.

Most of these studies focused on the appropriateness of the prescription of PAs in

The American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) have collaborated on the development of Clinical Practice Guidelines (CPGs) in patients with OPs. The first collaboration was in 2013 [5], where it was determined that it was not necessary to routinely prescribe PAs for dental procedures in patients with hip or knee replacements because, although PAs have been shown to reduce bacteria associated with dental procedures, no evidence links these bacteraemias to HO-PIs. Nevertheless, the authors expressed that this decision should be left to the discretion of the professional and the patient after weighing the benefits/risks. This workgroup concluded that PAs would be "rare" or "perhaps appropriate" for non-invasive treatments, meaning those that do not require gingival/mucosa manipulation/perforation, as well as for invasive treatments in healthy patients. Among severely immunocompromised patients, patients with non-controlled diabetes (with levels of glycosylated haemoglobin (HbA1c) ≥ 8 or blood glucose level ≥ 200 mg/dL) and/or patients with a history of OPI, the prescription of PAs would be considered "appropriate". Patients with severely immunosuppressed states can be classified into the following groups, according to the Center for

*3.2. Study Characteristics* 

as follows.

pendently?

priate?

priate?

pendently?

pendently?

7. Were there methods to minimize errors in data extraction?

propriate for the review question? 3. Was the search strategy appro-

by two or more reviewers inde-

by two or more reviewers inde-

by two or more reviewers inde-

used to search for studies adequate? 5. Were the criteria for appraising

4. Were the sources and resources used to search for studies adequate? 5. Were the criteria for appraising

bine studies appropriate?

and explicitly stated?

studies appropriate?

priate?

new research appropriate?

bine studies appropriate?

bine studies appropriate?

new research appropriate?

new research appropriate?

new research appropriate?

bine studies appropriate?

tion bias assessed?

studies appropriate?

tion bias assessed?

tion bias assessed?

tion bias assessed?

studies appropriate?

studies appropriate?

ported data?

pendently?

ported data?

ported data?

ported data?

8. Were the methods used to com-

4. Were the sources and resources used to search for studies adequate? 5. Were the criteria for appraising

6. Was critical appraisal conducted

6. Was critical appraisal conducted

pendently?

priate?

priate?

pendently?

pendently?

pendently?

studies appropriate?

studies appropriate?

studies appropriate?

9. Was the likelihood of publica-

7. Were there methods to minimize errors in data extraction?

7. Were there methods to minimize errors in data extraction?

10. Were policy and/or practice recommendations supported by the re-

6. Was critical appraisal conducted

8. Were the methods used to com-

11. Were the specific directives for

8. Were the methods used to com-

10. Were policy and/or practice recommendations supported by the re-

8. Were the methods used to com-

9. Was the likelihood of publica-

11. Were the specific directives for

9. Was the likelihood of publica-

11. Were the specific directives for

11. Were the specific directives for

10. Were policy and/or practice recommendations supported by the re-

10. Were policy and/or practice recommendations supported by the re-

9. Was the likelihood of publica-

7. Were there methods to minimize errors in data extraction?

Subsequently, the ADA [27] (2015) carried out a CPG with their workgroup following previous guidelines, not systematically recommending the PAs. Despite this, they suggest assessing the administration in diabetic or immunocompromised patients, including in the immunocompromised group those with antibiotic resistance or under treatment with systemic steroids/immunosuppressive drugs, the presence of some type of cancer, and/or with a history of chronic renal disease. The odd ratios (OR) related to the mentioned systemic alterations varied between 1.8 and 2.2 [30], although the magnitude of these values lacks clinical relevance [27]. Thus, this recommendation should be treated carefully. Also, they suggest assessing PAs on patients with a history of complications associated with joint replacement surgeries that will go through an invasive dental procedure and having an interview with the patient and a consultation with the orthopaedic surgeon. If it is favourable, the latter should recommend the adequate antibiotic prescription and, ideally, issue the pharmacological recipe.

Subsequently, the Canadian Agency for Drugs and Technologies in Health [28] (CADTH) (2016) conducted a CPG updating a previous consensus document [31] where they concluded that, although there were some cases of HOPIs after dental procedures, most of these infections were not caused by microorganisms present at the oral level and there was insufficient evidence to claim that taking PAs before a dental procedure could prevent HOPIs. Therefore, they do not recommend its prescription in patients with total joint replacements or with orthopaedic pins, plates, or screws.

In 2017, the Dutch Orthopaedic and Dental Societies [7] conducted a systematic review, concluding that there was no convincing evidence in the literature to justify PAs to avoid HOPIs. Human studies have not confirmed an increased risk of haematogenous infection in joint prostheses during the first two years after placement. Nonetheless, they did observe a higher susceptibility in those that were between two and five years old. Furthermore, the bleeding cannot be considered an isolated factor of bacteraemia, but rather that the gingival/mucosa (including chewing) manipulations cause a match between positive and negative pressures in the capillaries that could favour the diffusion of bacteria into the bloodstream [32]. Thus, positive capillary pressure could avoid the phenomenon. *Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12 **Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses. **Questions Rademacher et al. [7] (2017) CADTH [28] (2016) Sollecito et al. [27] (2013) Watters et al. [5] (2013)**  1. Is the review question clearly

#### *3.3. Risk of Bias within Studies* 2. Were the inclusion criteria appropriate for the review question?

Risk of bias and study quality analyses were performed independently by two review authors (J.-F.P.-C. and A.G.-S.). Using the predetermined 11 domains for the methodological quality assessment according to the JBI Prevalence Critical Appraisal Tool [26], we determined that all the papers [5,7,27,28] have a high-quality evaluation (7–11). Table 2 shows a more detailed description of the articles included. *Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12 *Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12 *Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12 *Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12 3. Was the search strategy appro-4. Were the sources and resources used to search for studies adequate? 5. Were the criteria for appraising

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

11. Were the specific directives for

9. Was the likelihood of publica-

11. Were the specific directives for

10. Were policy and/or practice recommendations supported by the re-

10. Were policy and/or practice recommendations supported by the re-

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

11. Were the specific directives for

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

**4. Discussion** 

**4. Discussion** 

**4. Discussion** 

**4. Discussion** 

**4. Discussion** 

7. Were there methods to minimize errors in data extraction?

propriate for the review question? 3. Was the search strategy appro-

by two or more reviewers inde-

Throughout the past few years, the recommendations regarding the need to prescribe

6. Was critical appraisal conducted

4. Were the sources and resources used to search for studies adequate?

used to search for studies adequate? 5. Were the criteria for appraising

9. Was the likelihood of publica-

used to search for studies adequate? 5. Were the criteria for appraising

7. Were there methods to minimize errors in data extraction?

8. Were the methods used to com-

6. Was critical appraisal conducted

the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

mize errors in data extraction?

by two or more reviewers inde-

by two or more reviewers inde-

10. Were policy and/or practice recommendations supported by the re-

6. Was critical appraisal conducted

8. Were the methods used to com-

9. Was the likelihood of publica-

7. Were there methods to minimize errors in data extraction?

11. Were the specific directives for

8. Were the methods used to com-

9. Was the likelihood of publica-

7. Were there methods to minimize errors in data extraction?

11. Were the specific directives for

8. Were the methods used to com-

9. Was the likelihood of publica-

10. Were policy and/or practice recommendations supported by the re-

10. Were policy and/or practice recommendations supported by the re-

bine studies appropriate?

bine studies appropriate?

bine studies appropriate?

tion bias assessed?

studies appropriate?

tion bias assessed?

tion bias assessed?

tion bias assessed?

tion bias assessed?

ported data?

pendently?

ported data?

ported data?

ported data?

ported data?

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

**4. Discussion** 

**4. Discussion** 

**4. Discussion** 

**4. Discussion** 

**4. Discussion** 

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

new research appropriate?

bine studies appropriate?

new research appropriate?

bine studies appropriate?

new research appropriate?

new research appropriate?

new research appropriate?


**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses. **Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses. **Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses. **Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses. **Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses. *Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12 *Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12 *Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

pendently?

priate?

pendently?

pendently?

pendently?

studies appropriate?

studies appropriate?

studies appropriate?

7. Were there methods to minimize errors in data extraction?

propriate for the review question? 3. Was the search strategy appro-

6. Was critical appraisal conducted

4. Were the sources and resources used to search for studies adequate?

used to search for studies adequate? 5. Were the criteria for appraising

—Yes; —No; —Unclear; —Not applicable.

by two or more reviewers inde-

mize errors in data extraction?

by two or more reviewers inde-

by two or more reviewers inde-

studies appropriate?

studies appropriate?

studies appropriate?

9. Was the likelihood of publica-

used to search for studies adequate? 5. Were the criteria for appraising

7. Were there methods to minimize errors in data extraction?

8. Were the methods used to com-

6. Was critical appraisal conducted

10. Were policy and/or practice recommendations supported by the re-

6. Was critical appraisal conducted

8. Were the methods used to com-

9. Was the likelihood of publica-

7. Were there methods to minimize errors in data extraction?

11. Were the specific directives for

8. Were the methods used to com-

9. Was the likelihood of publica-

7. Were there methods to minimize errors in data extraction?

11. Were the specific directives for

8. Were the methods used to com-

9. Was the likelihood of publica-

10. Were policy and/or practice recommendations supported by the re-

10. Were policy and/or practice recommendations supported by the re-

bine studies appropriate?

bine studies appropriate?

bine studies appropriate?

tion bias assessed?

studies appropriate?

tion bias assessed?

tion bias assessed?

tion bias assessed?

tion bias assessed?

ported data?

pendently?

ported data?

ported data?

ported data?

ported data?

—Yes; —No; —Unclear; —Not applicable.

new research appropriate?

bine studies appropriate?

new research appropriate?

bine studies appropriate?

new research appropriate?

new research appropriate?

new research appropriate?

**4. Discussion** 

9. Was the likelihood of publica-

11. Were the specific directives for

10. Were policy and/or practice recommendations supported by the re-

**4. Discussion** 

11. Were the specific directives for

10. Were policy and/or practice recommendations supported by the re-

**4. Discussion** 

11. Were the specific directives for

**4. Discussion** 

**4. Discussion** 

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

—Yes; —No; —Unclear; —Not applicable.

**4. Discussion** 

9. Was the likelihood of publica-

11. Were the specific directives for

11. Were the specific directives for

10. Were policy and/or practice recommendations supported by the re-

10. Were policy and/or practice recommendations supported by the re-

**4. Discussion** 

11. Were the specific directives for

**4. Discussion** 

**4. Discussion** 

7. Were there methods to minimize errors in data extraction?

propriate for the review question? 3. Was the search strategy appro-

7. Were there methods to minimize errors in data extraction?

by two or more reviewers inde-

by two or more reviewers inde-

by two or more reviewers inde-

by two or more reviewers inde-

**4. Discussion** 

used to search for studies adequate? 5. Were the criteria for appraising

6. Was critical appraisal conducted

4. Were the sources and resources used to search for studies adequate? 5. Were the criteria for appraising

bine studies appropriate?

bine studies appropriate?

bine studies appropriate?

new research appropriate?

bine studies appropriate?

new research appropriate?

bine studies appropriate?

new research appropriate?

new research appropriate?

new research appropriate?

tion bias assessed?

studies appropriate?

tion bias assessed?

tion bias assessed?

tion bias assessed?

tion bias assessed?

ported data?

pendently?

ported data?

ported data?

ported data?

ported data?

8. Were the methods used to com-

4. Were the sources and resources used to search for studies adequate? 5. Were the criteria for appraising

6. Was critical appraisal conducted

pendently?

priate?

priate?

pendently?

pendently?

pendently?

9. Was the likelihood of publica-

7. Were there methods to minimize errors in data extraction?

8. Were the methods used to com-

6. Was critical appraisal conducted

10. Were policy and/or practice recommendations supported by the re-

6. Was critical appraisal conducted

8. Were the methods used to com-

9. Was the likelihood of publica-

7. Were there methods to minimize errors in data extraction?

11. Were the specific directives for

8. Were the methods used to com-

9. Was the likelihood of publica-

7. Were there methods to minimize errors in data extraction?

11. Were the specific directives for

8. Were the methods used to com-

9. Was the likelihood of publica-

10. Were policy and/or practice recommendations supported by the re-

10. Were policy and/or practice recommendations supported by the reand explicitly stated?

priate?

priate?

2. Were the inclusion criteria ap-

1. Is the review question clearly

and explicitly stated?

8. Were the methods used to com-

11. Were the specific directives for

11. Were the specific directives for

4. Were the sources and resources used to search for studies adequate? 5. Were the criteria for appraising

ported data?

6. Was critical appraisal conducted

by two or more reviewers inde-

bine studies appropriate?

new research appropriate?

tion bias assessed?

ported data?

7. Were there methods to minimize errors in data extraction?

8. Were the methods used to com-

9. Was the likelihood of publica-

10. Were policy and/or practice recommendations supported by the re-

11. Were the specific directives for

10. Were policy and/or practice recommendations supported by the re-

2. Were the inclusion criteria appropriate for the review question? 3. Was the search strategy appro-

new research appropriate?

new research appropriate?

studies appropriate?

ported data?

ported data?

9. Was the likelihood of publica-

10. Were policy and/or practice recommendations supported by the re-

11. Were the specific directives for

pendently?

priate?

new research appropriate?

bine studies appropriate?

tion bias assessed?

ported data?

priate?

and explicitly stated?

and explicitly stated?

and explicitly stated?

bine studies appropriate?

new research appropriate?

10. Were policy and/or practice recommendations supported by the re-

new research appropriate?

11. Were the specific directives for

bine studies appropriate?

**4. Discussion** 

ported data?

**4. Discussion** 

new research appropriate?

new research appropriate?

new research appropriate?

new research appropriate?

**4. Discussion** 

bine studies appropriate?

tion bias assessed?

tion bias assessed?

9. Was the likelihood of publica-

studies appropriate?

tion bias assessed?

tion bias assessed?

ported data?

ported data?

pendently?

new research appropriate?

ported data?

ported data?

tion bias assessed?

ported data?

**4. Discussion** 

ported data?


*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

**Questions Rademacher et al. [7]** 

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

**(2017)** 

**(2017)** 

**(2017)** 

**CADTH [28] (2016)** 

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

**CADTH [28] (2016)** 

**(2017)** 

**(2017)** 

and explicitly stated?

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

1. Is the review question clearly

2. Were the inclusion criteria appropriate for the review question? 3. Was the search strategy appro-

4. Were the sources and resources

**Questions Rademacher et al. [7]** 

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

#### **Table 2.** *Cont.* **Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses. by two or more reviewers indeused to search for studies adequate? used to search for studies adequate? used to search for studies adequate? used to search for studies adequate? 2. Were the inclusion criteria ap-1. Is the review question clearly 1. Is the review question clearly 1. Is the review question clearly

**Questions Rademacher et al. [7]** 

6. Was critical appraisal conducted

priate?

1. Is the review question clearly

2. Were the inclusion criteria appropriate for the review question? 3. Was the search strategy appro-

**Questions Rademacher et al. [7]** 

**Questions Rademacher et al. [7]** 

**Questions Rademacher et al. [7]** 

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

4. Were the sources and resources used to search for studies adequate? 5. Were the criteria for appraising

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

**Questions Rademacher et al. [7]** 

and explicitly stated?

studies appropriate?

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

**(2017)** 

**(2017)** 

priate?

1. Is the review question clearly

1. Is the review question clearly

1. Is the review question clearly

2. Were the inclusion criteria appropriate for the review question?

**Questions Rademacher et al. [7]** 

2. Were the inclusion criteria appropriate for the review question?

2. Were the inclusion criteria appropriate for the review question?

4. Were the sources and resources

**Questions Rademacher et al. [7]** 

4. Were the sources and resources

4. Were the sources and resources

8. Were the methods used to compaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United 8. Were the methods used to com-8. Were the methods used to com-7. Were there methods to mini-**4. Discussion**  7. Were there methods to mini-**4. Discussion 4. Discussion 4. Discussion**  by two or more reviewers indeby two or more reviewers inde-5. Were the criteria for appraising 5. Were the criteria for appraising 4. Were the sources and resources 4. Were the sources and resources 4. Were the sources and resources 4. Were the sources and resources tion bias assessed? —Yes; —No; —Unclear; —Not applicable.

#### bine studies appropriate? mize errors in data extraction? Throughout the past few years, the recommendations regarding the need to prescribe mize errors in data extraction? Throughout the past few years, the recommendations regarding the need to prescribe Throughout the past few years, the recommendations regarding the need to prescribe pendently? 11. Were the specific directives for studies appropriate? used to search for studies adequate? used to search for studies adequate? used to search for studies adequate? 10. Were policy and/or practice recommendations supported by the re-10. Were policy and/or practice recommendations supported by the re-10. Were policy and/or practice recommendations supported by the re-9. Was the likelihood of publica-**4. Discussion**

9. Was the likelihood of publica-10. Were policy and/or practice recommendations supported by the re-11. Were the specific directives for —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. 9. Was the likelihood of publication bias assessed? 10. Were policy and/or practice recommendations supported by the reported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. 9. Was the likelihood of publication bias assessed? 10. Were policy and/or practice recommendations supported by the reported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. 8. Were the methods used to com-9. Was the likelihood of publica-10. Were policy and/or practice recommendations supported by the re-11. Were the specific directives for —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. 8. Were the methods used to combine studies appropriate? 9. Was the likelihood of publication bias assessed? 10. Were policy and/or practice recommendations supported by the reported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. 7. Were there methods to minimize errors in data extraction? 8. Were the methods used to combine studies appropriate? 9. Was the likelihood of publication bias assessed? 10. Were policy and/or practice recommendations supported by the reported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United 7. Were there methods to minimize errors in data extraction? 8. Were the methods used to combine studies appropriate? 9. Was the likelihood of publication bias assessed? 10. Were policy and/or practice recommendations supported by the reported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United —Yes; —No; —Unclear; —Not applicable. Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental 6. Was critical appraisal conducted by two or more reviewers independently? 7. Were there methods to minimize errors in data extraction? 8. Were the methods used to combine studies appropriate? 9. Was the likelihood of publication bias assessed? 10. Were policy and/or practice recommendations supported by the reported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, 6. Was critical appraisal conducted by two or more reviewers independently? 7. Were there methods to minimize errors in data extraction? 8. Were the methods used to combine studies appropriate? 9. Was the likelihood of publication bias assessed? 10. Were policy and/or practice recommendations supported by the reported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, 5.criteria for appraising 6. Was critical appraisal conducted by two or more reviewers inde-7. Were there methods to minimize errors in data extraction? 8. methods used to com-9. Was the likelihood of publica-10. Were policy and/or practice recommendations supported by the re-11. Were the specific directives for —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  5. Were the criteria for appraising studies appropriate? 6. Was critical appraisal conducted by two or more reviewers independently? 7. Were there methods to minimize errors in data extraction? 8. Were the methods used to combine studies appropriate? 9. Was the likelihood of publication bias assessed? 10. Were policy and/or practice recommendations supported by the reported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  5.criteria for appraising studies appropriate? 6. Was critical appraisal conducted by two or more reviewers independently? 7. Were there methods to minimize errors in data extraction? 8. methods used to combine studies appropriate? 9. Was the likelihood of publication bias assessed? 10. Were policy and/or practice recommendations supported by the reported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  5. Were the criteria for appraising studies appropriate? 6. Was critical appraisal conducted by two or more reviewers independently? 7. Were there methods to minimize errors in data extraction? 8. Were the methods used to combine studies appropriate? 9. Was the likelihood of publication bias assessed? 10. Were policy and/or practice recommendations supported by the reported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  —Yes; —No; —Unclear; —Not applicable. Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 11. Were the specific directives for —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and ported data? 11. Were the specific directives for new research appropriate? —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and —Yes; —No; —Unclear; —Not applicable. Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and ortho-10. Were policy and/or practice recommendations supported by the re-11. Were the specific directives for —Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some au-—Yes; —No; —Unclear; —Not applicable. **4. Discussion**  Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some au-Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36], and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

bine studies appropriate?

used to search for studies adequate?

studies appropriate?

pendently?

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

**(2017)** 

**CADTH [28] (2016)** 

**CADTH [28] (2016)** 

**Questions Rademacher et al. [7]** 

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

**CADTH [28] (2016)** 

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**Sollecito et al. [27] (2013)** 

**Sollecito et al. [27] (2013)** 

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**CADTH [28] (2016)** 

**CADTH [28] (2016)** 

**Questions Rademacher et al. [7]** 

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**Sollecito et al. [27] (2013)** 

**Sollecito et al. [27] (2013)** 

**(2017)** 

**Watters et al. [5] (2013)** 

**Watters et al. [5] (2013)** 

**(2017)** 

**(2016)** 

**Sollecito et al. [27] (2013)** 

**Sollecito et al. [27] (2013)** 

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**(2017) CADTH [28]** 

**Sollecito et al. [27] (2013)** 

**CADTH [28] (2016)** 

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription.

**Sollecito et al. [27] (2013)** 

**Watters et al. [5] (2013)** 

**Watters et al. [5] (2013)** 

**Watters et al. [5] (2013)** 

**CADTH [28] (2016)** 

**Watters et al. [5] (2013)** 

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**Watters et al. [5] (2013)** 

**CADTH [28] (2016)** 

**Sollecito et al. [27] (2013)** 

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

curred in immunocompromised patients, 4.2% were related to dental procedures, and

and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

curred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

curred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

*Antibiotics* **2022**, *11*, x FOR PEER REVIEW 7 of 12

Throughout the past few years, the recommendations regarding the need to prescribe

**Watters et al. [5] (2013)** 

**Sollecito et al. [27] (2013)** 

**Table 2.** JBI Critical Appraisal Tool [26] for Systematic Reviews and Research Syntheses.

**Watters et al. [5] (2013)** 

**Sollecito et al. [27] (2013)** 

**Watters et al. [5] (2013)** 

**Watters et al. [5] (2013)** 

Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some au-Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some autreatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, the first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. —Yes; —No; —Unclear; —Not applicable. Throughout the past few years, the recommendations regarding the need to prescribe PAs in dental procedures to avoid OPIs have suffered diverse variations. In this regard, paedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** thors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been thors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been Kao et al. [38] carried out a cohort study of 57,066 patients with knee or hip prostheses undergoing invasive dental treatments. They were compared to patients that had not undergone dental treatment using a ratio of 1:1, describing OPIs rates of 0.57% and 0.61%, respectively. The multivariable analysis of the COX regression did not find any relationship between the invasive dental procedures and OPIs. On the other hand, OPIs happened in 0.20% of patients of the subcohort who were prescribed with PAs and in 0.18% who were not prescribed PAs, without significant differences.

treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is thors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects thors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third oc-Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third oc-Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third oc-Undoubtedly, OPI is an important complication for the patient and with a high cost for the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8]. Despite this, their consistent use is currently not justified, as there is no evidence that bacteraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third octhe first guidelines recommended prescribing PAs during the first two years after orthopaedic surgery [32]. Some years later, they suggested carrying it out for the rest of the individual's life [33] and, at present, some countries, such as Australia [14], the United Kingdom [15], Canada [16] and New Zealand [17], advise against its routine prescription. Undoubtedly, OPI is an important complication for the patient and with a high cost for and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9]. In implant surgery, there are three moments when bacteraemia can be caused: during (1) the injection of local anaesthesia, (2) the rise of mucoperiosteal flaps, and (3) the placement of the dental implant [39]. Regarding the anaesthetic technique, the infiltrative methods, which are the ones used in oral implantology, produce a significantly lower proportion of positive blood cultures than the modified and conventional intraligamen-

0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

curred in immunocompromised patients, 4.2% were related to dental procedures, and

and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

the healthcare system, so the tendency, of oral and/or maxillofacial surgeons and orthopaedic surgeons to prescribe PAs before invasive dental procedures is understandable [8].

teraemias following dental procedures are directly related to HOPIs [5,30,34]. Some authors found HOPI rates after total knee arthroplasty of 22.1%, out of which one-third occurred in immunocompromised patients, 4.2% were related to dental procedures, and 7.2% to cutaneous infections. In the remaining cases, they did not find a causal factor [35]. Thus, their incidence is very low (2.9%; 6/224) and usually related to dental abscesses [36]**,** and often it is hard to prove the relationship between a HOPI to the carried out dental treatment. In this regard, the expected benefits do not exceed the possible adverse effects that could develop due to the consumption of antibiotics [37]. In this sense, it has been determined that the risk of suffering an OPI after a dental procedure without PAs is 0.00023 (0.00012–0.00034), while the OR associated with the PAs prescription is 0.7 [9].

tous techniques (16% vs. 50% vs. 97%, respectively)—the level of basal bacteraemia is 8% [40]. Lockhart [41] suggested that using local anaesthesia with epinephrine could decrease the transit of bacteria to the bloodstream by reducing the flow. Furthermore, the rate of secondary bacteraemia to implant surgery is very low, which was only described by Piñeiro et al. [39] The authors analysed secondary bacteraemia with the placement of implants in patients that rinsed with chlorhexidine digluconate (CLX) at 0.2% (10 mL for 1 min) (test group) before the anaesthetic injection versus a control group that did not use any type of antimicrobial. The level of bacteraemia in the control group was 2% versus 6.7% in the test group. They only observed differences between patients with positive and negative cultures concerning the intervention time (92.5 ± 24.7 min vs. 64.8 ± 20.2 min, respectively), but not so for the history of periodontal disease, the level of oral health, or the number of placed implants. These surgeries were carried out with general anaesthesia, as well as a local one, which has been related to a higher risk of bacteraemia compared to just administering local anaesthesia at 30 s (89% vs. 53%; OR = 5.04), 15 min (64% vs. 24%; OR = 5.37), and 60 min (21% vs. 4%; OR = 6.5) [42].

On the other hand, Watters et al. [5] identified bacteria associated with a higher risk of OPIs, such as *Staphylococcus* spp. (31.5%), specifically, *S. aureus* (26.0%) and *S. epidermidis* (6.5%), Gram-positives species (9.0%), and *Streptococcus* spp. (6.5%). The isolated species after secondary bacteraemia of implant placement were *Streptococcus viridans* and *Neisseria* [39], which are not directly related to OPs complications. Also, certain oral hygiene procedures carried out daily by patients have a risk of associated bacteraemia that is not inconsiderable, with higher proportions of OPI-causing bacteria than in invasive procedures related to oral implantology [5].

Noori et al. [43] (2019) established for the first time some recommendations in patients treated with foot and ankle surgeries, including total ankle arthroplasty. The bacteria implicated in post-surgery infections in hip and/or knee joint prosthesis infections are similar to those responsible for foot and ankle surgeries, so they determined that the recommendations should be the same.

If it is decided to prescribe PAs, the first-choice antibiotic would be 2 g of amoxicillin, 30–60 min before the procedure and, to those allergic to penicillin, 500 mg of azithromycin or clarithromycin [7,39]. Currently, there are only recommendations based on evidence regarding the placement of unitary implants in ordinary conditions [23] and bone regeneration with the placement of implants in one or two phases [21]. In both procedures, the recommended guideline is 2 or 3 g of amoxicillin, one hour before the intervention [21,23] and, in allergic patients, 500 mg of azithromycin one hour before surgery [24], which would be equivalent to what is recommended to prevent OPIs.

The current guidelines recommend assessing PAs in non-controlled diabetic patients, those immunocompromised, and/or in patients with a history of OPI. For a long time, it has been presumed that immunocompromised patients have a higher risk of HOPIs. Nonetheless, it has not been proved after dental procedures, since they develop comparable bacteraemia to the ones developed by healthy individuals, and with the latter, there is no evidence that there is a higher risk [7]. On the other hand, the European Association of Endodontics [44] recommends prescribing PAs in patients with OPs during the three months following orthopaedic joint surgery. Dental implants entail an elective surgery, so it does seem prudent to postpone the intervention during this time. Also, dental implant surgery is not indicated for the described systemic states until the disease has been controlled. The only scenario where the treatment could be assessed in these patients would be in those with AR being treated with biological agents modifying the disease, and despite this, different authors associated it with a higher risk of early placement failure and peri-implantitis [45,46].

The relationship between the periodontal state, or the level of hygiene, and the level of bacteraemia was not established [9,39]. Nonetheless, any implant procedure must be done in an oral cavity without any pathology. Another preventive measure is using perioperative antiseptics, such as CLX. Although ADA/AAOS was not able to conclude that rinsing with different topical antimicrobials before a dental procedure prevents HOPIs [5], further studies found that CLX rinses reduce the incidence of secondary bacteraemia in dental extractions by 12% [47–49], possibly due to a reduction of the quantity of inoculated bacteria. This is a simple preventive measure without evidence of adverse reactions. Thus, its use is recommendable despite its low efficacy [47]. Furthermore, as a chemo-preventive measure against the accumulation of biofilm, its use is recommended in the immediate post-surgery period, a time when oral hygiene procedures could experience difficulties [50].

Given that the placement of dental implants currently involves the prescription of PAs in healthy patients, future lines of research should focus on establishing the incidence of infections following implant procedures in those patients with OPs. It would also be interesting to study topical antiseptics, such as CLX, to reduce secondary bacteraemia in implant procedures.

#### *Strengths and Limitations*

This systematic review presents several strengths, such as a previous record of protocol, free search in the literature (including grey literature), the searching process of studies, data extraction, and the risk analysis bias performed in duplicate, which determined a high overall quality of the included studies.

Nonetheless, with the low number of studies available in the literature, the present systematic review has limitations, so the external validity of the results of this review should be confirmed with future studies.

#### **5. Conclusions**

No evidence suggests a relationship between dental implant surgery and a higher risk of infection of OPs. Therefore, the prescription of PAs in these patients is not justified. Nonetheless, the recommended PA dose in a dental implant procedure in healthy patients is comparable to the dose recommended to avoid infections in OPs. We should evaluate the prescription of PAs in patients with a history of infections in their OPs in second-stage implant surgeries. Furthermore, it would be wise to avoid surgeries three months after orthopaedic surgery.

**Author Contributions:** Conzand E.V.-O.; methodology, A.-O.S.-P. and E.V.-O.; software, A.G.-S.; validation, Á.J.-G., I.O.-G., A.G.-S. and L.M.-G.; formal analysis, M.-V.M.-M., E.V.-O., N.K. and M.-V.M.-M.; investigation, A.-O.S.-P. and J.-F.P.-C.; resources, L.M.-G. and E.V.-O.; data curation, A.-O.S.-P., J.-F.P.-C. and N.K.; writing—original draft preparation, A.-O.S.-P., J.-F.P.-C., A.G.-S., I.P. and D.V; writing—review and editing, A.-O.S.-P., E.V.-O., J.-F.P.-C., I.P. and D.V.; visualization, M.- V.M.-M., Á.J.-G. and I.O.-G.; supervision, E.V.-O.; project administration, E.V.-O. and A.G.-S. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Data are available in a publicly accessible repository.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

