Antibiotics For Dental Work Following Joint Replacement
Persons who have undergone joint replacement surgery are at risk for developing infections of their implanted joints. In severe cases of infection, a person may experience the loss of bone support to the implant and require surgery to repair it.
It is for this reason that healthcare providers make every effort to counsel their patients on ways to avoid infection. Deep infection is a serious problem affecting between 4% of primary and 15% of revision knee replacements.
There have been changing recommendations as to whether antibiotics should be mandatory for joint replacement recipients when undergoing dental work. Starting in 2012, the recommendations were modified to say that most people would not require antibiotics for routine dental work but that treatment may be given to people at the highest risk of infection.
Inclusion And Exclusion Criteria
The studies included provided data regarding a PJI of a THA or TKA around the time of a dental procedure. These studies included contained patient-level information regarding type of arthroplasty, time from dental procedure, organism isolated, and the demographics of sex, age, and presence of comorbidities. Studies were excluded if they did not include patient-level information, the specific organism isolated, or timing from dental procedure or were written in languages other than English.
Antibiotic Guidelines For Patients Undergoing Dental Procedures After Hip Or Knee Replacement
Spread of oral bacteria into the bloodstream from oral microorganisms can occur after invasive dental procedures and can potentially lead to infection of a hip or knee prosthesis.
The following guidelines are provided for patients undergoing dental procedures after Hip or Knee Replacement. These guidelines are in accordance with recommendations provided by the Australian Arthroplasty Society.
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Do You Need Antibiotics Before Your Dental Visit
Antibiotics treat bacterial infections. Antibiotic prophylaxis is the taking of antibiotics before a surgery or other procedure that may release large numbers of bacteria into your bloodstream to decrease the chance of infection in another part of your body. During dental procedures that may cause bleeding, such as tooth extractions, large numbers of bacteria from the mouth can enter the bloodstream. In persons at high risk of infection or with certain heart conditions, there is concern that these bacteria may cause infection in other parts of the body . The immune system normally kills these bacteria, but antibiotic prophylaxis may offer these people extra protection. The American Heart Association recommends that antibiotics be used prior to some dental procedures for persons with certain heart conditions, who may be at risk for developing an infection of the heart.
Numerous studies have pointed out that blood bacteria may occur during normal daily activities, such as chewing, tooth brushing and flossing. It is likely that these daily activities induce many more bacteremias than typical dental procedures. While studies do show a strong association between certain dental procedures and bacteremia, they dont show good evidence that there is a direct link between dental procedure associated bacteremia and infections in the heart or prosthetic joints.
Heres what the experts say.
Postoperative Antibiotic Prophylaxis For Dental Patients Provincial Hip And Knee Committees Weigh In
ABJHI Archive
In 1997, the American Dental Association and the American Academy of Orthopaedic Surgeons published the first advisory statement on antibiotic prophylaxis for dental patients with prosthetic joints. This advisory statement was updated in 2003 with new information and concluded that AP is not routinely indicated for most patients with total joint arthroplasty who undergo dental procedures, and that, although bacteremia can cause hematogenous seeding of total joints, there is no evidence linking dental procedures to prosthetic joint infection. These advisory statements were fairly specific concerning which patient populations the clinician might choose to give AP, including the period of time following joint implantation, dental procedures of concern, antibiotic protocols, and alternatives, and there was discussion of the benefits and risks from this practice. In 2009, the AAOS released a new statement: Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider AP for all total joint replacement patients prior to any invasive procedure that may cause bacteremia.1-5
To summarize:
In Alberta, some patients will receive AP prior to dental work at the individual surgeons discretion. The Provincial Hip and Knee Care Path has been updated to reflect this decision, reading:
References
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Dental Treatment After Three Months In Patients With A Normal Functioning Joint Replacement:
- Routine dental treatment in a low risk patient: NO antibiotic prophylaxis required.
- Higher risk dental treatment: Discuss with your orthopaedic surgeon. Antibiotic prophylaxis likely to be recommended prior to dental procedure :
At risk patients:Diabetics Patients with rheumatoid arthritisPatients taking immunosuppressive medications Patients with previous history of prosthetic infection.
- High risk procedures: eg dental abscess, root canal procedures
Ada And Orthopedic Society Antibiotic Recommendations
The American Dental Association is the professional society for dentists. The ADAs official recommendations are as follows: For patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. They recommend abstaining from prophylactic antibiotics because they assert that there is no evidence that dental procedures are associated with PJIs. They also argue that there is no evidence to suggest that giving patients prophylactic antibiotics before dental procedures prevents PJIs. The ADA asserts that antibiotic resistance is a major concern, and the theoretical benefits are not enough to make up for this concern. However, they state that each patient should be considered individually, taking into account their personal risk factors.
American Academy of Orthopedic Surgeons
Just as the ADA is the professional society for American dentists, the AAOS is the professional society for orthopedic surgeons. They have released their own guidelines for surgeons when considering prophylactic antibiotics for dental procedures.
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Other Uses For Antibiotics In Dentistry
If your dentist detects signs of an acute or chronic infection in your mouth, particularly when accompanied by fever, swelling or other signs, you may be prescribed antibiotics. Tooth infections occur when bacteria enter a tooths root, causing pain, tissue death and buildup of pus. Called an abscess or abscessed tooth, this kind of infection can spread to other areas of the head. Treatments for abscesses can include antibiotics, root canals and tooth extractions. Periodontal disease can also lead to serious gum abscesses.
Antibiotic prophylaxis before typical periodontal, third molar or other surgeries is usually not necessary. Depending on your personal medical history, however, you may still be a candidate for premedication. For example, antibiotic prophylaxis might be useful for patients undergoing invasive dental procedures, who also have compromised immune systems, due to, for instance, diabetes, rheumatoid arthritis, cancer, chemotherapy and chronic steroid use.
Finally, always provide your dentist or physician with a complete medical history and discuss whether antibiotic prophylaxis before dental treatment is right for you. Also, remember that brushing, flossing, good diet and visiting your dentist regularly help maintain good oral health, prevent tooth and gum infections, and avert the need for more aggressive dental procedures and medications.
Antibiotic Prophylaxis And Joint Surgery
In the past, people who have had a joint replacement, such as a hip or a knee replacement, were often prescribed antibiotic prophylaxis before invasive dental procedures. While this still may be necessary for some individuals, in general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended routinely prior to dental procedures to prevent prosthetic joint infection.
Based on careful review of the scientific literature, the American Dental Association found that dental procedures are not associated with prosthetic joint implant infections, and that antibiotics given before dental procedures do not prevent such infections. The American Dental Association has found it is no longer necessary for most dental patients with orthopedic implants to have antibiotic prophylaxis to prevent infection.
A joint expert group of the American Dental Association and the American Academy of Orthopaedic Surgeons found moderate strength evidence that dental procedures are unrelated to implant infection and that antibiotic prophylaxis prior to dental procedures does not reduce the risk of subsequent implant infection. The group stated that practitioners might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.
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Antibiotics Used In Dentistry
- Penicillin: A common class of antibiotic with minor side effects that treats a broad range of bacterial infections
- Amoxicillin and ampicillin: Antibiotics in the penicillin family that treat a greater variety of infections
- Metronidazole: An antibiotic with antimicrobial properties that is regularly used to treat acute ulcerative gingivitis and is frequently used in conjunction with penicillin
- Erythromycin: A broad spectrum antibiotic administered to patients allergic to penicillin
- Cephalosporin: An antibiotic appropriate for those with penicillin allergies and used to treat a range of bacterial infections
- Tetracycline: An antibiotic used to treat a spectrum of infections, can cause grey stains on erupting teeth, and should not be prescribed to pregnant women or children under 12
- Sulphonamides: A group of antibiotics that can penetrate cerebrospinal fluid, often prescribed as a prophylactic to prevent bacterial meningitis for those with high infection risk
- Co-trimoxazole: An antibiotic that targets specific bacterial infections and requires a bacteriological sensitivity test
Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al.
Circulation 2007 116:1736-54.
Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al.
J Am Dent Assoc 2008 139 Suppl:3S-24S Accessed July 2018.
What is antibiotic prophylaxis. American Dental Association. J Amer Dent Assoc. 2016. Vol. 147 p. 526.
Evolution Of Prophylaxis Guidelines
Since the 1950s there has been a progressive reduction in the use of antibiotics in the prevention of endocarditis following dental therapy . Different countries have made different recommendations. The changes in the USA in 2007 limited prophylaxis to patients with conditions including prosthetic cardiac valves or valves repaired with prosthetic material, previous infective endocarditis, unrepaired and repaired congenital cardiac defects and cardiac transplants with subsequent valvulopathy. Patients with mitral valve prolapse, even with severe regurgitation, no longer required prophylaxis.18
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Heart Problems That Call For Antibiotics In Dental Procedures
Virtually all guideline committees around the world recommend antibiotic prophylaxis for those individuals at high risk of an adverse outcome from infective endocarditis and who are undergoing invasive dental procedures. Today, the AHA only recommends antibiotics before dental procedures for patients with the highest risk of infection, those who have:
If youre not sure about the guidelines for your heart condition, check with your heart specialist. If you have one of these conditions, always tell your dentist. Also, alert your dentist if – you are allergic to any antibiotics or other medications.
Will I Need To Take Antibiotics After Having A Hip Replacement
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Antibiotics For Dental Work
Certain types of dental work can cause infections elsewhere in the body. There are many different types of bacteria in the mouth. Depending on the patient, the bacteria can cause an infection in different organ systems. For example, some patients can become bacteremic, meaning they develop a bacterial infection in their blood. Others may develop pneumonia, cardiovascular infections, or inflammatory conditions. Different patients have different risk factors.
Antibiotics And Dental Treatment
So what is the story with antibiotics and dental treatment? There is no definitive scientifically based answer only recommendations from various bodies. It would be very difficult to set up a proper scientific study to examine this issue because we are talking about a very small number of infections in a very large number of patients. The American Dental Association and the American Academy of Orthopaedic Surgeons have produced a number position statements on this topic. In 2009 these bodies recommended that antibiotics should be given before any kind of dental treatment or examination but in 2012 watered this recommendation down, leaving it up to the surgeon and patient in each case. Guidelines regarding antibiotic use in this circumstance are certainly not uniform across the world.
At the moment, until there is definitive evidence to the contrary, I would recommend all joint replacement patients are given antibiotics an hour before any significant dental treatment . Amoxycillin 1g or Erythromycin is generally what I prescribe. It is thought that there is increased risk in patients with diabetes or those with suppressed immune systems and early days after joint replacement surgery .
As an aside, any patient with a joint replacement who develops a bacterial infection anywhere should seek medical attention early and have appropriate antibiotic therapy instituted.
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New Dental Antibiotic Prophylaxis Recommendations For Patients With Total Joint Replacements
The ADA has since turned away from its aggressive approach of recommending that everyone with a total joint replacement get antibiotics before invasive dental work.
Last year I mentioned that the ADA had formed a task force to research the literature and form new guidelines on the decision of how to give antibiotic prophylaxis to patients who had undergone total joint replacement. The ADA has since removed the recommendation from their website that all patients with joint replacements be premedicated with antibiotics before dental work. They have now posted the following recommendation :
The American Dental Association and the American Academy of Orthopedic Surgeons are currently in the process of developing evidence-based clinical guidelines on the topic of antibiotic prophylaxis for patients with orthopedic implants undergoing dental procedures. The ADA and AAOS do not have a joint recommendation at this time. There are differing opinions on the need for antibiotic prophylaxis. These opinions/statements are presented below to assist the dentist in making informed decisions about the prescription of antibiotics. The ADA believes that the professional goal should be consensus among the dentist and physician, which is the expressed goal being pursued in the ongoing ADA/AAOS project.
Dental Treatment After Hip Or Knee Replacement
Deep Infection after Total Joint Replacement can be a serious, devastating and costly complication, often necessitating an extended hospital stay, multiple operative procedures and prolonged antibiotic use which in some cases can be lifelong. Speak to anyone who has had a serious infection and they will let you know its not a pleasant experience.
It is thought that a small proportion of late infections result from bacteria which normally live within the mouth or oral cavity. It is well recognized that these oral bacteria travel into the bloodstream at the time of dental treatment or even with vigorous teeth cleaning/flossing. These now circulating bacteria can deposit themselves onto the surface of a joint replacement implant and once there adhere strongly to the metal where they multiply and if unlucky lead to an infection which is difficult for the body to eradicate. It has been advocated that antibiotics given before dental treatment may reduce the chances of a blood borne infection occurring.
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Antibiotics Before Dental Work For Joint Replacements
Last year I wrote an article about dental antibiotic prophylaxis, which talked about why dentists prescribe antibiotics for their patients to take before many dental procedures.
In that post I mentioned that anybody who has a joint replacement is supposed to get antibiotics prescribed to them before certain dental procedures. The reason for this is that there are millions of bacteria in our mouth that may enter our bloodstream during certain dental procedures. When an artifical joint gets infected, it normally is considered a failure.
Since antibiotics are very cheap and they can help prevent the infection of an artificial joint, it seems like a no-brainer to give antibiotics to patients before invasive dental procedures so that the catastrophic loss of an artificial joint can be avoided.
However, there really isnt conclusive evidence that antibiotics prevent joint infections in the average healthy person. That is why, in the American Dental Associations original 1997 guidelines on dental antibiotic prophylaxis for joint replacements, and in the 2003 guidelines, the ADA stated, Antibiotic prophylaxis is not routinely indicated for most dental patients with total joint replacements.
Dental Treatment Hip Surgery And Antibiotics
There has been debate for years about whether or not antibiotics should be given to patients who have had a hip replcement, and who then need dental treatment. My advice has been to take a broad spectrum antibiotic such as augmentin if you are to have an extraction, or treatment of an abscess. Routine dental treatment such as a filling or scale and polish doesnt require any prophylactic antibiotics. Recent statements from the American Academy of Orthopaedic Surgeons and NICE suggest that there is no evidence that antibiotics make any difference to the risk of developing a joint replacement infection. Ive attached a summary of the relevant article for information. If you are in doubt, speak to your surgeon and dentist Good oral hygiene is essential in patients with joint replacements and I advise my patients to see a dentist if they havent had a check up for a year before undergoing surgery.
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