ADA /AAOS Look at Joint Implant Infections After Dental Care

Janis C. Kelly

April 24, 2013

The first evidence-based clinical practice guideline to be codeveloped by a both the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) suggest that prophylactic antibiotics might not always be needed for routine dental procedures in patients with joint implants, that the jury is still out on the usefulness of topical antibiotics during dental procedures, and that patients with joint implants should be particularly careful about oral hygiene. The recommendations from the AAOS/ADA working group were published in the April 17 issue of the Journal of Bone and Joint Surgery.

According to the authors, more than 300,000 hip replacements and more than 650,000 knee replacements were performed in the United States in 2010, and the mean rate of infections around hip, knee, and spine implants was 2%. Treating these infections typically required additional surgery and prolonged antibiotic therapy.

"Recommendation 1 proposes that the clinicians consider changing the practice of prescribing prophylactic antibiotics for patients who undergo dental procedures. High-strength evidence suggests that antibiotic prophylaxis reduces the incidence of bacteremia that occurs after dental procedures. We did not find, however, direct evidence that bacteremia increases the risk of periprosthetic joint infection. As such, one has to question whether bacteremia is a good surrogate of periprosthetic joint infection," coauthor Calin S. Moucha, MD, told Medscape Medical News. Dr. Moucha is associate chief for joint replacement surgery at Mount Sinai Medical Center, New York City.

Dr. Moucha added that he continues to recommend prophylaxis for most of his patients, as there is little evidence for not continuing this practice. "Having said that, it is probably reasonable to discontinue routine administration of prophylactic antibiotics in patients with good oral hygiene who go to their dentists on a regular basis. Unfortunately, many patients do not have the resources to routinely see their dentists once or twice a year, and as such, their oral health is probably suboptimal," Dr. Moucha said.

"The causes of infection included the entry of microbes into the wound during surgery, hematogenous spread, recurrence of infection in a previously infected joint, and contiguous spread of infection from a local source," the authors write.

Recommendation 2 said that because of inconclusive evidence, the guideline authors were unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants who were undergoing dental procedures.

"Recommendation 3 says that although there is not reliable evidence linking poor oral health to prosthetic joint infection, the working group consensus is that 'patients with prosthetic joint implants or other orthopaedic implants [should] maintain appropriate oral hygiene,' " Dr. Moucha said.

"The risk associated with not going to the dentist on a regular basis is likely higher than the risk associated with not giving prophylactic antibiotics on a regular basis," he continued. "Maintaining good oral health by brushing teeth on a regular basis, using oral antiseptics, and seeing a dentist on a regular basis to evaluate potential problems is critical. The biggest challenge that I've seen is that a large majority of patients do not have dental insurance, and a large number of dentists in [New York City] do not participate in most plans. This makes it difficult for most patients to pay for good dental healthcare."

"If I have a patient who has had a joint replacement or any other type of joint surgery, my first step is to call the surgeon," said Matthew Messina, DDS, a dentist in private practice in Cleveland, Ohio, who was not involved in developing the guidelines. "I explain what the dental procedure is likely to entail and ask, 'What would you like us to do with regard to antibiotic prophylaxis for this patient?' For each patient, you generally have to do this only once unless something changes in the patient's situation. I ask for the orthopedic surgeon's recommendations, get them in writing, and put that into the patient's record. We also routinely ask every patient at every visit about joint implants."

Dr. Messina told Medscape Medical News that dentists should be advising patients to be sure to mention any joint implants when they are making a dental appointment. That would give the dentist time to consult with the orthopedic surgeon and determine the course of care.

"When in doubt, we should probably premedicate," Dr. Messina said. However, he also noted that antibiotics are not completely innocuous. "Allergic reactions occur in 5% to 10% of patients taking amoxicillin, for example, and we all are more concerned about the risk of building 'superbugs,' but bacterial infection of a joint prosthesis is a major problem," he said.

Dr. Messina added, "I think we are doing a better job of making people in general, as well as other health professionals, aware of how important dental health is to the rest of the body. A cleaner mouth leads to a healthier body."

Dr. Moucha has received speaker's bureau fees from 3M and owns stock or stock options in Auxilllium. Dr. Messina has disclosed no relevant financial relationships.

J Bone Joint Surg Am. 2013;95:745-747. Abstract