Antibiotic Prophylaxis for Patients with Artificial Hip Joints Undergoing Dental Procedures

Introduction to Guidelines

• The American Academy of Orthopedic Surgeons (AAOS) and American Dental Association (ADA) recommend maintaining good oral hygiene as the primary preventive measure against prosthetic joint infections, rather than routine antibiotic prophylaxis for patients with prosthetic joints undergoing dental procedures 1

Patient Selection for Antibiotic Prophylaxis

• Antibiotic prophylaxis should be considered only 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
• The decision to use antibiotic prophylaxis should be based on individual risk factors, with approximately 12% of patients with prosthetic joints requiring prophylaxis 2

Evidence Against Routine Antibiotic Prophylaxis

• A well-conducted case-control study showed that neither dental procedures nor antibiotic prophylaxis before dental procedures were associated with the risk of prosthetic hip or knee infections, supporting the recommendation against routine antibiotic prophylaxis 1
• Multiple studies show no statistical association between dental procedures without antibiotic prophylaxis and prosthetic joint infections, indicating limited evidence for effectiveness 2
• 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

Recommended Regimens for High-Risk Patients

• 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

Importance of Oral Hygiene

• 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 7
• Brushing teeth twice daily with fluoride toothpaste using the Bass or modified Bass method, and cleaning between teeth once daily with appropriate interdental cleaners, using a soft toothbrush to reduce the risk of bleeding, is recommended by the American Dental Association 7
• Professional dental cleaning is necessary to remove plaque and calculus, as recommended by the American Dental Association 7
• Rinsing with alcohol-free mouthwash at least four times daily, maintaining proper denture care, and avoiding painful stimuli (smoking, alcohol, spicy foods, hot drinks) are recommended by the American Dental Association 7
• Evaluating response to treatment within 1-2 weeks is essential, and for patients with periodontitis, regular maintenance visits every 3-4 months are necessary to prevent recurrence, as recommended by the American Dental Association 7

Dental Procedures and Antibiotic Prophylaxis

• The decision to use antibiotic prophylaxis should be based on the type of dental procedure, with higher risk procedures involving manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa, including dental extractions, periodontal procedures, and endodontic procedures beyond the apex, as recommended by the European Society of Cardiology and the American Heart Association 8, 3, 8, 6, 5, 9
• 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, 9, 8

Infection Control and Prevention

• 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 10
• 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, 7