Dental Screening Prior To Hip or Knee Arthroplasty

The literature regarding oral health maintenance prior to elective total joint arthroplasty (TJA) included 4 low quality studies presented in 3 groups (dental clearance, dental evaluation, and dental screening) based on study design.

Two studies have evaluated the effect of mandating formal preoperative dental clearance (performed by a dentist) prior to TJA (Kwan, 2023; Lampley, 2014). Kwan et al. propensity score matched 8,654 patients who had been referred for preoperative dental clearance to 8,654 patients who were not referred based on age, gender, and body mass index (Kwan, 2023). The authors identified no difference between groups in the rate of postoperative prosthetic joint infection (PJI) nor in the bacteriological makeup of infectious organisms in patients undergoing TJA. Furthermore, Lampley et al. compared postoperative infection rates of 365 TJA patients who had received dental clearance to a retrospective cohort of 218 hip fracture patients treated with hip arthroplasty who did not have clearance (Lampley, 2014). Although 8.8% of patients who underwent dental clearance had periodontal disease that required treatment preoperatively, the authors found no significant difference in the rate of early postoperative PJI between the cleared versus uncleared groups (1.7% versus 2.5%, p=0.512). Based on the published data the four patients in the hip fracture cohort reported as having a PJI do not appear to meet the 2011 Musculoskeletal Infection Society Criteria as detailed in the methods. However, eliminating these four reported PJIs in the hip fracture cohort would continue to show no benefit for dental clearance.

Fenske et al. performed a retrospective analysis on 777 elective arthroplasty patients comparing early (< 4 weeks from TJA) PJI rates in patients who were not screened, screened by their orthopedic surgeon, or were screened by a dentist (Fenske, 2023). Although the authors found no significant difference in postoperative PJI rates among non-screened versus screened (1.6% versus 1%), infection rates were significantly lower in those patients screened by a dentist compared to an orthopedic surgeon (0% versus 2.3%, p=0.021) with all infections occurring in patients screened by the orthopaedic surgeon. A significantly higher rate of patients screened by dentists underwent a dental procedure prior to their TJA compared to patients screened by orthopaedic surgeons (23.6% vs. 0%, p=0.001).
Finally, a single study looked at the prevalence of PJI in patients with and without a documented dental evaluation prior to undergoing primary TJA. Over four-years, Sonn et al. retrospectively analyzed a consecutive cohort of patients undergoing 2457 elective arthroplasty procedures, finding that 79.1% had a documented dental evaluation, 15.0% had no documented dental evaluation, and 5.9% were edentulous (Sonn, 2019). An extraction of at least one tooth prior to surgery was identified as necessary in 11.5% of dental evaluations. While the authors do not document the time between dental evaluation and surgery, the median time between extraction and surgery was 52 days (IQR, 25-99; range 1-853). Overall, dental evaluation was not associated with a decreased risk of PJI. While the authors found that patients who required a dental extraction trended towards having a higher rate of postoperative complications (adjusted hazard ratio 1.24, p=0.57), they also noted these patients were more likely to exhibit features of immune suppression and diabetes.

Benefits/Harms of Implementation
Clinicians should encourage patients to maintain good dental health and can recommend a formal preoperative assessment by a trained dental practitioner when 1) a history of poor dental hygiene is disclosed, 2) patients exhibit comorbidities such as poorly controlled diabetes, malnutrition, smoking, or immunosuppression that could put them at risk of dental pathology, and 3) when both the cost and feasibility of a dental consultation are appropriate to the patient. The final decision to require formal dental consultation should be a shared decision between the provider and the patient.

Outcome Importance
Periprosthetic joint infection is a devastating complication after TJA associated with increased morbidity and mortality. Fortunately, rates of PJI are reported as low as 1%. It is unclear whether implementation of dental screening may identify patients at high risk and further mitigate the risk of PJI.

Cost Effectiveness/Resource Utilization
Implementing a mandatory dental screening could add significant costs for the patient beyond the screening, as patients who undergo a dental screening are more likely to need a dental procedure before proceeding to TJA. As such, this recommendation reduces cost and limits resource utilization. However, the decision should be made with the patient after discussing the potential risks and benefits of a dental screening due to the potential cost associated with the dental screening.

Acceptability
Given the individual biases based on clinician experience and training, it might be difficult to accomplish widespread acceptance of the current recommendation.

Feasibility
While the encouragement of good oral hygiene should always be supported, the decision to implement a dental screening program prior to TJA in the setting of the United States should be not taken lightly. Recent data reveals that approximately 68.5 million American adults (27% of the population) lack dental insurance (Carequest, 2023), a number that is nearly three times the percentage of those without health insurance. This discrepancy highlights the considerable challenge in ensuring equitable access to dental care, a challenge that continues to afflict specific minority populations over others (Fellows, 2022). Due to the lack of ample evidence to support mandatory clearance, screening, or evaluation by a dental professional prior to TJA, we do not recommend this practice. Mandating dental clearance may inadvertently decrease access to TJA care for certain patient populations. Consensus opinion supports optimization of dental hygiene prior to elective TJA.

Future Research
Four studies have attempted to identify approaches to dental clearance, screening, and evaluation that can improve oral health and decrease potentially infectious foci prior to TJA in patients with teeth with mixed findings. The retrospective nature of the study designs, lack of adequate cohort matching, and minimal details in the dental clearance evaluation and subsequent treatment needs/recommendations are limitations of the literature on this topic. Future studies on this topic should consider taking these limitations into account.