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Infection after joint replacement is a devastating complication. The incidence following primary total knee or hip replacement is approximately 1-3%. This number may seem small; however, for the 1-3% that it affects, it can be life-altering. The treatment options for joint infection are determined by a variety of factors, including the infecting organism, duration of infection, and patient age and functional demands.
For chronic infections, the gold standard treatment is two-stage replacement arthroplasty. This requires that the patient return to operating room, where the implant is removed and a temporary antibiotic spacer is implanted. The patient then receives approximately 6-8 weeks of IV antibiotics. If the infection is cleared at that time, the patient returns to the OR for a third surgery in which the temporary implant is removed and the definitive joint reconstruction is performed. As one could imagine, this is clearly a frustrating, painful, and expensive experience that we hope all patients can avoid.
This leads us to the question: “When do infections occur?“ In overly simplistic terms, infections occur early or late. Late infections are commonly hematogenous in nature, which means that bacteria enter the bloodstream from another source, gain access to the implants, multiply, and cause infection. Unfortunately, bacteria can gain access to the bloodstream during dental procedures. This leads us to the next question: “Could bacteria released during certain dental procedures result in a periprosthetic joint infection?” Unfortunately, much of current literature investigating this is unclear. The available evidence has not definitively proven an association between dental procedures and prosthetic joint infections. Historically, however, many surgeons have prophylactically prescribed antibiotics for patients with a hip or knee replacements prior to dental procedures as precaution. In response to this, the American Academy of Orthopedic Surgeons and American Dental Association published a collaborative clinical guideline on the “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures” in 2012. This guideline recommended that “the practitioner might consider discontinuing the practice of routinely prescribing routine antibiotics” based on the current evidence. This guideline is in stark contrast to an earlier statement by the American Academy of Orthopaedic Surgeons in 2009, which recommended that “clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteremia.” Unfortunately, according to Paul Lachiewicz, MD, “no evidence supports a definitive recommendation that patients with prosthetic implants should NOT receive prophylactic antibiotics prior to undergoing dental procedures.”
As you can see, dental prophylaxis after joint replacement a confusing and hot topic among joint replacement surgeons. The available evidence is meager, and most studies are judged to be of low level. In my personal opinion, the ideal approach is to assess individual patient risk factors and proceed with a shared decision-making approach. The key points about dental prophylaxis are as follows:
Clearly, there are potential benefits and risks associated with dental prophylaxis. For patients who have had a joint replacement, I recommend that you discuss dental prophylaxis with your surgeon to determine whether you should be taking them!
