Prosthetic Joint Infections and Dental Procedures

Introduction to Prosthetic Joint Infections

• Prosthetic joint infections can be prevented through good oral hygiene, including regular dental check-ups, proper brushing, daily flossing or interdental cleaning, and professional dental cleanings at appropriate intervals, as recommended by the American Academy of Orthopaedic Surgeons 1, 2

Recommendations for Antibiotic Prophylaxis

• The American Academy of Orthopaedic Surgeons and the American Dental Association recommend against routine antibiotic prophylaxis for dental procedures in patients with knee replacements, emphasizing the importance of good oral hygiene for preventing prosthetic joint infections 1, 2
• The American Academy of Orthopaedic Surgeons and the American Dental Association suggest that clinicians consider discontinuing routine antibiotic prophylaxis for patients with prosthetic joints, as stated in their 2013 revised recommendations 1, 2
• The American Heart Association recommends antibiotic prophylaxis for patients with prosthetic cardiac valves, previous infective endocarditis, congenital heart disease, or cardiac transplant recipients who develop cardiac valvulopathy, as well as patients with completely repaired congenital heart disease with prosthetic material during the first 6 months after the procedure, or repaired congenital heart disease with residual defects at or adjacent to the site of a prosthetic patch or device 3
• The American Academy of Orthopedic Surgeons (AAOS) and American Dental Association (ADA) recommend antibiotic prophylaxis for specific high-risk patients, including immunocompromised patients, patients with a history of previous prosthetic joint infection, solid organ transplant recipients on immunosuppression, patients with inherited immune deficiency diseases, and severely immunocompromised patients 1, 2
• Recommended antibiotic regimens for high-risk patients are as follows:

1, 3, 4, 5

• A single dose of clindamycin is sufficient, and prolonged prophylaxis increases the risk of adverse events without additional benefit 2
• The timing of administration is critical, and clindamycin should be administered 30-60 minutes before the procedure to ensure adequate tissue concentration 6

Dental Procedures and Antibiotic Prophylaxis

• Dental procedures that involve manipulation of gingival tissue, procedures involving the periapical region of teeth, or procedures that perforate the oral mucosa, may require antibiotic prophylaxis for high-risk patients, as recommended by the European Society of Cardiology and the American Heart Association 7, 3, 7, 6, 5, 8
• The following procedures do not require antibiotic prophylaxis, even in high-risk patients: local anesthetic injections in non-infected tissues, taking dental radiographs, placement/adjustment of removable prosthodontic/orthodontic appliances, treatment of superficial caries, removal of sutures, loss of deciduous teeth, and trauma to lips and oral mucosa 6, 8, 7
• Routine anesthetic injections through non-infected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth, and bleeding from trauma to lips or oral mucosa, do not require antibiotic prophylaxis for patients with cardiac devices 3

Risk of Infection and Adverse Events

• The risk of device infection from transient bacteremia during dental procedures is considered very low compared to the risks associated with indiscriminate antibiotic use 9
• Indiscriminate use of antibiotics can lead to antibiotic resistance, C. difficile infections, and adverse drug reactions 9
• Current evidence does not support routine antibiotic prophylaxis for patients with prosthetic joints, as the risk of taking antibiotics (20% chance of adverse events requiring medical attention) outweighs the benefit (<1% risk of prosthetic joint infection) 2

Prevention and Maintenance

• Maintaining good oral hygiene, including regular dental check-ups, proper brushing twice daily with fluoride toothpaste, daily flossing or interdental cleaning, and professional dental cleanings at appropriate intervals, is the most effective prevention strategy against prosthetic joint infections 1, 2
• The American Dental Association recommends thorough mechanical plaque removal through proper brushing and flossing, combined with professional dental cleaning, as the first-line treatment for gum infection (gingivitis), while antibiotics should be reserved only for severe cases with systemic involvement or in immunocompromised patients 10
• After each patient treatment, cleaning and disinfecting dental unit surfaces with an EPA-registered "hospital disinfectant" labeled for "tuberculocidal" activity, such as a 1:100 dilution of household bleach (sodium hypochlorite), is necessary, as recommended by guidelines 11
• Maintaining optimal oral hygiene through proper brushing, flossing, and regular dental check-ups is more important than antibiotic prophylaxis for preventing infective endocarditis, as recommended by the American Heart Association and the American Dental Association 2, 10
• The presence of fever or other signs of systemic infection should prompt blood cultures before administering antibiotics to avoid masking a potential existing infection 3