Approximately 450,000 total joint arthroplasties are performed annually in the United States. Deep infections of these total joint replacements usually result in failure of the initial operation and the need for extensive revision. Owing to the use of perioperative antibiotic prophylaxis and other technical advances, deep infection occurring in the immediate postoperative period resulting from intraoperative contamination has been reduced markedly in the past 20 years.
Patients who are about to have a total joint arthroplasty should be in good dental health prior to surgery and should be encouraged to seek professional dental care if necessary. Patients who already have had a total joint arthroplasty should perform effective daily oral hygiene procedures to remove plaque (for example, by using manual or powered toothbrushes, inter-dental cleaners or oral irrigators) to establish and maintain good oral health. The risk of bacteremia is far more substantial in a mouth with ongoing inflammation than in one that is healthy and employing these home oral hygiene devices.1
Antibiotic prophylaxis is not routinely indicated for most dental patients with total joint replacements.
Bacteremias can cause hematogenous seeding of total joint implants, both in the early postoperative period and for many years following implantation.2 It appears that the most critical period is up to two years after joint placement.3 In addition, bacteremias may occur in the course of normal daily life4–6 and concurrently with dental and medical procedures.6 It is likely that many more oral bacteremias are spontaneously induced by daily events than are dental treatment–induced.6 Presently, no scientific evidence supports the position that antibiotic prophylaxis to prevent hematogenous infections is required prior to dental treatment in patients with total joint prostheses.1 The risk/benefit7,8 and cost/effectiveness7,9 ratios fail to justify the administration of routine antibiotic prophylaxis. The analogy of late prosthetic joint infections with infective endocarditis is invalid, as the anatomy, blood supply, microorganisms and mechanisms of infection are all different.10
Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity; allergy; and development, selection and transmission of microbial resistance.
It is likely that bacteremias associated with acute infection in the oral cavity,11,12 skin, respiratory, gastrointestinal and urogenital systems and/or other sites can and do cause late implant infection.12 Any patient with a total joint prosthesis with acute orofacial infection should be vigorously treated as any other patient with elimination of the source of the infection (incision and drainage, endodontics, extraction) and appropriate therapeutic antibiotics when indicated.1,12 Practitioners should maintain a high index of suspicion for any unusual signs and symptoms (such as fever, swelling, pain, joint that is warm to touch) in patients with total joint prostheses.
Antibiotic prophylaxis is not indicated for dental patients with pins, plates and screws, nor is it routinely indicated for most dental patients with total joint replacements. This position agrees with that taken by the ADA Council on Dental Therapeutics13 and the American Academy of Oral Medicine14 and is similar to that taken by the British Society for Antimicrobial Chemotherapy.15 There is limited evidence that some immunocompromised patients with total joint replacements (Table 1
) may be at higher risk of experiencing hematogenous infections.12,16–23 Antibiotic prophylaxis for such patients undergoing dental procedures with a higher bacteremic risk (as defined in Table 2) should be considered using an empirical regimen (Table 3). In addition, antibiotic prophylaxis may be considered when the higher-risk dental procedures (again, as defined in Table 2) are performed on dental patients within two years post–implant surgery,3 on those who have had previous prosthetic joint infections and on those with some other conditions (Table 1).
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