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Do Patients With Prosthetic Joints Need Antibiotics Before Invasive Dental Work? by Dr. Thomas Paumier

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Categories: Oral Pathology, Pharmacology, and Cariology;
Yes? No? Maybe? Sometimes? 

Rethinking antibiotic prophylaxis for patients with prosthetic joints

by Dr. Thomas Paumier

With nearly 1 million prosthetic knee and hip replacements done yearly, and more than 4 million estimated to be done yearly by 2030,1 it’s likely that every day a patient with prosthetic joints presents in a practice requiring an invasive dental procedure. That, in turn, means dentists must decide whether antibiotic prophylaxis (AP) is necessary for these patients before treatment.

There is still confusion among dentists and orthopedic surgeons about whether to use AP, even though the current guidelines have been in place at least five years. That confusion is understandable, considering there have been six different information statements or guidelines from the American Dental Association (ADA) and the American Academy of Orthopedic Surgeons (AAOS) in the past 25 years.

The most recent ADA clinical practice guideline (CPG), published in JADA in 2015, states: “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended before dental procedures to prevent prosthetic joint infection.”2

And in 2017, the AAOS released an appropriate use criteria (AUC) that identified a very narrow group of patients for whom it would be appropriate to consider using antibiotic prophylaxis. This cohort has all of the following co-morbidities: immunocompromised, diabetic and having previous joint infections. The AUC states: “[I]t would be reasonable to assume that most patients will fall outside of these criteria and therefore lay outside the confines of our strict definitions … and therefore do not need antibiotic prophylaxis.”3

So, why have we used AP for patients with prosthetic joints? Knowing that invasive dental procedures cause bacteremia, which can potentially lead to distant site infections, and that we have used AP for patients with prosthetic heart valves or a history of infective endocarditis, it seemed reasonable that AP would be appropriate for patients with prosthetic joint replacements. However, studies show there is no association between dental procedures and prosthetic joint infections (PJIs). And there is evidence that antibiotics provided before oral care do not prevent prosthetic joint infections.4,5

Additionally, there is the potential for significant harms from taking antibiotics. It is estimated that 1%–2% of joint arthroplasties will develop a PJI, usually within two years. Those occurring within three months are considered early infections and likely occurred at the time of surgery; late infections occur after three months and are attributed to hematogenous spread.

However, many infections occurring in the first year could be smoldering infections from the time of surgery. The vast majority of PJI are caused by staphylococcal bacteria, with viridans (oral) streptococci involved in less than 5% of cases.5 In a study by Swan, when a late PJI was associated with a preceding sentinel event, it was always related to a dermatologic infection or cellulitis resulting in hematogenous spread, and caused by staph bacteria.6

Transient bacteremia occurs with most dental procedures and with routine daily activities, including chewing, brushing and flossing. It lasts, on average, from six to 60 minutes per episode, and it is estimated that bacteremia from normal daily activities amounts to 90 hours per month.7 So, if oral bacteria are involved with PJI, it is much more likely to result from chronic bacteremia rather than an isolated dental procedure. If AP is necessary before dental procedures, why is it not necessary before eating or brushing and flossing teeth?


Antibiotics’ benefits and risks

What happens when we take antibiotics before a dental procedure, and does this prevent distant site infections? Antibiotics taken before dental procedures reduce but do not eliminate bacteria from the bloodstream, and decreased bacteremia does not necessarily mean prevention of distant site infections. Many PJIs occur in patients who have taken AP before dental procedures.

A study by Dios showed that taking 2g of amoxicillin before extraction reduced bacteremia by approximately 50%. Clindamycin was ineffective at reducing bacteremia before extraction and is the equivalent of having not taken an antibiotic.8 Clindamycin should never be used for antibiotic prophylaxis, even when AP is indicated (recommended cardiac conditions). Keflex 2g is recommended for patients who are allergic to amoxicillin and have not had an anaphylactic reaction, severe skin reaction or angiodema. Azithromycin 500mg or clarithromycin 500mg are indicated for true amoxicillin-allergic patients.

You might be thinking that you’ve used AP for prosthetic joint patients for years without problems, so isn’t it reasonable to simply continue to do so? The answer is no: There is minimal if any benefit from using AP, and there are many risks to using antibiotics, including anaphylaxis, gastrointestinal distress, antibiotic resistance and Clostridioides difficile (C. diff) infection.9 An estimated 35,000 deaths occur yearly because of antibiotic-resistant infections, and another 29,000 deaths occur yearly from C. diff infections.10

Community-acquired C. diff infections are outpacing infections acquired in hospitals and physician offices, and most are associated with antibiotic use. The top three risk factors for C. diff infection are recent hospitalization, recent antibiotic use and being over age 65—something almost all patients undergoing joint replacements have in common. The surgery is done in a hospital or outpatient surgery center, they receive intraoperative IV antibiotics and often are over age 65.

A C. diff infection can occur up to six weeks after having taken an antibiotic, so we may be unaware of patients who develop C. diff infections after our recommendation for AP. A study by Thornhill et al. showed 13 deaths per 1 million single doses of 600mg clindamycin used for AP, all from C. diff- or antibiotic-associated colitis. Amoxicillin had the least adverse drug reactions and resulted in no deaths.11

But that is today; clindamycin was not associated with as many adverse drug reactions decades ago. Will amoxicillin be associated with more adverse drug reactions and death in the future? A study by Costelloe showed patients developed antibiotic resistance from a therapeutic course of antibiotics for UTI or skin infections for up to 12 months. The greater the number or duration of antibiotic courses in the previous 12 months, the greater the likelihood of resistant bacteria isolated from that patient.12 So while we think of antibiotic resistance as a global problem only, it’s a problem at an individual level as well.


Conflicting opinions confuse patients

Unfortunately, many orthopedic surgeons still recommend AP for life, using outdated prescribing regimens and not following the current guidelines. Additionally many surgeons advise patients that they should not have dental treatment for three months after their arthroplasty … to which I ask patients if their surgeon also told them they shouldn’t brush or floss their teeth for three months, because those activities induce a bacteremia similar to that of a dental procedure. I also ask if their surgeon inquired about their oral health and the last time they saw a dentist before they had surgery.

The highest risk of infection is at the time of surgery, yet in my experience orthopedic surgeons seldom ask patients if they have existing dental problems before surgery. There’s no need to delay any dental treatment after joint replacement, but conflicting recommendations from the surgeon and dentist put patients in an awkward situation: They essentially have to decide for themselves whether to use AP or delay dental care.

Orthopedic surgeons and dentists in many other countries don’t recommend AP for patients undergoing invasive dental procedures, and there is no evidence that late PJI incidence is any higher in those countries, which include Australia, Brazil, Canada, Denmark, France, Netherlands, Norway, Portugal and the United Kingdom.

I hope this article has given you the knowledge and confidence to make an informed decision about (not) using AP for patients with prosthetic joints. It would be the rare situation where I would consider using AP for a patient with a prosthetic joint; I haven’t recommended or written a prescription for AP for a patient with a prosthetic joint in more than 10 years.

If an orthopedic surgeon recommends AP and the patient prefers to use it, I ask the patient to have the surgeon prescribe it, because if you write the prescription at the recommendation of the surgeon, you are the one liable for any adverse events related to the antibiotic use.

As a practical matter, if a patient prefers to use AP and forgot to take it, I will give them amoxicillin or azithromycin at the time of the appointment, advising them of the risks of antibiotic use and that there is no evidence of benefit. Medico-legally, there is no defense if you have given AP without proper informed consent and the patient ends up in the hospital from a C. diff infection. If you treat a patient without using AP and they develop a PJI caused by viridans strep, there is no way to determine if it occurred as a result of bacteremia from normal daily activities or the dental procedure. You may still be sued, but the science would be in your favor.

It is our responsibility as dentists to determine the best care for the patients we treat, including whether AP is appropriate. Long-held practices are hard to change, but taking the time to educate patients who have a prosthetic joint about why AP is not necessary is worthwhile. It may just save their life. And it will ensure you are practicing to the standard of care.

Reference
1. Kremers, H.M., Larson, D., et al. “Prevalence of Total Hip and Knee Replacement in the United States.” J Bone Joint Surg Am. 2015 Sep 2; 97(17):1386–1397.
2. Sollecito, T.P., Abt, E.,, Lockhart, P.B., Truelove, E., Paumier, T.M., et al. “The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients with Prosthetic Joints: Evidence-Based Clinical Practice Guideline for Dental Practitioners—A Report of the ADA Council of Scientific Affairs.” JADA 2015; (1):11–16.
3. http://www.orthoguidelines.org/go/auc.
4. Berbari, E.F., Osman, D.R., Carr, A., et al. “Dental Procedures As Risk Factors for Prosthetic Hip or Knee Infection: A Hospital-Based Prospective Case-Control Study.” Clin Infect Dis. 2010; 50(1):8–16.
5. Thornhill, M.H., Crum, A., Rex, S., Stone, T., Campbell, R., Bradburn, M., Fibisan, V., Lockhart, P., Springer, B., Baddour, L., and Nicholl, J. “Analysis of Prosthetic Joint Infections Following Invasive Dental Procedures in England.” JAMA Network Open. 2022; 5(1):e2142987.
6. Swan, J., Dowsey, M., Babazadeh, S., Mandaleson, A., and Choong, P.F. “Significance of Sentinel Infective Events in Haematogenous Prosthetic Knee Infections.” ANZ J Surg. 2011; 81(1- 2):40–45.
7. Guntheroth, W.G. “How Important Are Dental Procedures As a Cause of Infective Endocarditis?” Am J Cardiol 1984; 54:797–801.
8. Dios, P.D., Carmens, I.T., et al. “Comparative Efficacies of Amoxicillin, Clindamycin and Moxifloxacin in Prevention of Bacteremia Following Dental Extractions.” Antimicrob Agents Chemother. 2006 Sep; 50(9): 2996–3002.
9. Thornhill, M.H., Dayer, M.J., Durkin, M.J., Lockhart, P.B., and Baddour, L.M. “Risk of Adverse Reactions to Oral Antibiotics Prescribed by Dentists.” J Dent Res. 2019; 98(10):1081–7.
10. CDC’s 2019 Antibiotic Resistance Threats Report.
11. Thornhill, M.H., Dayer, M.J., Prendergast, B., Baddour, L.M., Jones, S., and Lockhart, P.B. “Incidence and Nature of Adverse Reactions to Antibiotics Used As Endocarditis Prophylaxis.” J Antimicrob Chemotherapy, April 2015.
12. Costelloe, C., Metcalfe, C., Lovering, A., Mant, D., and Hay, A.D. “Effect of Antibiotic Prescribing in Primary Care on Antimicrobial Resistance in Individual Patients: Systematic Review and Meta-Analysis.” BMJ 2010; 340:c2096.

Author Bio
Dr. Thomas Paumier
Dr. Thomas Paumier, a cum laude graduate of The Ohio State University College of Dentistry, completed a general practice residency at St. Elizabeth Medical Center in Youngstown, Ohio. He has been in private practice since 1988 in Canton, Ohio, where he also is on the faculty of the Cleveland Clinic Mercy Hospital GPR.

Paumier was a member of the American Dental Association and American Academy of Orthopedic Surgeons expert panels that wrote the clinical practice guidelines and appropriate use criteria for antibiotic prophylaxis for prosthetic joint patients. He also co-authored the ADA Clinical Practice Guideline for Appropriate Antibiotic Use for Odontogenic Infections and was the 2019 recipient of the ADA Evidence-Based Dentistry Clinical Practice Award. He is a fellow in the International and American College of Dentists and a past president of the Ohio Dental Association.

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